Embracing Legacy Student Application
2017-2018 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.
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
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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