Embracing Legacy Student Application
2016-2017 Student Program Application
Embracing Legacy
Application Date *
Youth Information *
Student Demographics
Youth Name (Last, First Middle) *
Your answer
Date of Birth - Youth *
Use xx/xx/xxxx format
Your answer
Youth Age (Age 2 - 17) *
*Must be full potty trained.
Your answer
Gender - Youth *
Ethnicity - Youth (Optional)
Please note that this information is optional and is being collected for research and grant purposes only.
Are you a member of Revealing Truth Ministries? *
Membership is NOT required. This is for informational purposes only.
Address - Youth *
Your answer
City - Youth *
Your answer
State - Youth *
Example: FL
Your answer
Zip - Youth *
5 digit Zip codes only
Your answer
Home Phone Number - Youth
Use format: xxx-xxx-xxxx
Your answer
Mobile Number - Youth
Use format: xxx-xxx-xxxx
Your answer
School Name (Include Pre, ELEM, MS or HS) *
Your answer
School T ype *
Grade *
Program Information
Program Selection *
Choose all that your youth will participate in
If Tutoring was selected, which subject?
Your answer
Primary Program
If youth is participating more than one entity, which is primary?
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