Personal Information Form

Student Information

Name*

First Middle Last

Email*

Primary Address*

Street Address Address Line 2 City State ZIP Code

School/Site*

Program at YWCA Minneapolis*

Grade*

Student ID #

Ethnic Heritage*

If you chose Native American, what is your tribal affiliation?

Date of Birth (mm/dd/yyyy)*

Age*

My gender identification is...*

Is your family eligible for free or reduced price lunch at your school?*

Language(s) spoken at home:*

I live with...*

I have a parent currently in the military.*

YWCA programs currently involved in:

Primary Youth Counselor's Name