STRIVE Teen Application/Interest Form 
Please fill out the ENTIRE form. Thank you! 
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Email *
Name (First, Middle, Last) *
Pronouns 
Email (Please no school emails) *
Age  *
Home Address *
Phone Number *
Ethnicity  *
What is the name of your HS?  *
School ID  *
What grade are you in?  *
Median Family Income Table 
The following is a table designed to aid in classifying the financial status of beneficiaries. 
For example: A beneficiary of 4 family members (people that live at home) with a Family Annual Income of less than $28,250 is classified as Extremely Low-Income. (MFI- Median Family Income)
Number of Family Members in your House?  *
Family Income (Use the MFI Table Above) *
Computer Skills *
Availability  *
Early AM to Afternoon (7am to 12pm)
AM to Early Afternoon (9am to 12pm)
Afternoon (12pm to 4pm)
Late Afternoon to Early Evening (2pm to 6pm)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
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