EC County YA Registration 19-20
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First Name
Last Name
Street Address
City
Zip Code
Telephone
Date of Birth
MM
/
DD
/
YYYY
Gender
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Race
Clear selection
Parent First Name
Parent Last Name
Student has an Individualized Education Program
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Student is at-risk by school District's definition
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Expected H.S. Graduation Date
MM
/
DD
/
YYYY
GPA
Current Grade in school
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Program Type
Program Area (select one)
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Starting Wage per hour
Business Name
Business Street Address
Business located in what City
Business Zip Code
Mentor First Name
Mentor Last Name
Mentor Telephone
Mentor Address
Mentor Email
Submit
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