Become a Scholar

GENERAL INFORMATION

Full Name:

Email:

School:

Grade Level:

Overall GPA:

Address:

Student ID Number:

Birth Date:

Gender:
(select one)MaleFemaleotherdecline to state

Gender Pronouns:
(select one)he/himshe/herthey/theirze/zir

Ethnicity:
(select one)African AmericanAsianCambodianCaucasianFilipinoHispanic/LatinxMaoriMiddle EasternMixedN/ANative AmericanOther AsianOther Ethnic GroupPacific IslanderSoutheast Asian

Languages Spoken:

Cell Phone:

Home Phone:

Were you referred to us by someone? If so, who?

Residence Status:
(select one)Single ParentTwo ParentsExtended FamilyFosterOther

Sibling Previously in Program?
(select one)YesNo
If 'Yes', What is their name?

Are you currently participating in any of these pre-college programs? (Check all that apply)
AVIDCal-SoapGear-UpBoys and Girls ClubEd. Talent SearchOther
PARENT/GUARDIAN INFORMATION
PARENT/GUARDIAN 1:
Full Name:

Relationship to Applicant:

Employer:

Work Phone Number:

Cell Phone Number:

Email:

Preferred Spoken Language:

Highest Level of Education Completed:
(select one)8th GradeHigh SchoolAssociate's DegreeBachelor's Degree (or higher)
PARENT/GUARDIAN 2:
Full Name:

Relationship to Applicant:

Employer:

Work Phone Number:

Cell Phone Number:

Email:

Preferred Spoken Language:

Highest Level of Education Completed:
(select one)8th GradeHigh SchoolAssociate's DegreeBachelor's Degree (or higher)
INCOME INFORMATION
Number of People Living in Your Household:

Is your family receiving public assistance (check any that apply)?
(none)Social SecurityUnemploymentDisabilityFree LunchReduced Price LunchFood Stamps/CalfreshMedi-Calother
Taxable income range (See line 43 on Form 1040, line 27 on 1040 A, line 6 on 1040 EZ):
(select one)$16,245 or below$16,246 - $21,855$21,856 - $27,465$27,466 - $33,075$33,076 - $38,685$38,686 - $44,295$44,296 - $49,905$49,906 - $55,515$55,516 or greater
Attach unofficial transcript: Digital unofficial transcript can be downloaded from Parent/Student VUE. (max file size: 5MB)

By submitting this form, I certify that the information provided on this pre-screening questionnaire is true to the best of my knowledge and that any misrepresentation may be cause for denial or cancellation of admission.