Aspiring Youth Academy
Email address *
Name of student
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Date of Birth *
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Address *
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Self Identified Gender *
Ethnicity *
Emergency Contact (Name, relationship and number) *
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High School Attending *
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Grade *
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Foster/Kinship Care *
If yes, please provide information of the foster care
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Household Size (How Many People) *
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Annual Income *
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Dietary Needs *
If yes, please explain.
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Medication Usage *
If yes, please explain.
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Attended Aspiring Youth Academy Camp Before? *
If so, please explain your connection to the program.
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A copy of your responses will be emailed to the address you provided.
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