Graduate 313 Intake Form
Contact
First Name
Last Name
Email address
Home Street Address
Apartment Unit or #
Home City
Home State
Home Zip Code
Mobile Number
To which gender do you most identify?
Please select...
Male
Female
Gender Variant/Non-Conforming
Prefer Not to Answer
Ethnicity
Please select...
Hispanic or Latino
Not Hispanic or Latino
Race
Please select...
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Two or more races
General Information
Traditional College Student is defined as ages 18-24 and currently enrolled in a College/University or a Trade school.
Non-Traditional College Student is defined a
s ages 18-24 and NOT currently enrolled in a College/University or a Trade school.
Adult Learner is defined as ages 25+ regardless of enrollment in a College/University or Trade school.
What category best fits your needs?
Please select...
Middle School Student
High School Student
Traditional College Student
Non-Traditional College Student
Adult Learner (Obtaining GED, HS Diploma, Certificate Pathway, Post Secondary Degree, Transitioning jobs or career fields)
I know someone who fits into one of these categories
Please refer to the descriptions above when selecting your response.
Which statement do you most identify with?
Please select...
I am an adult who is looking to return to school but I'm not sure what my options are
I am an adult learner who is working towards a degree or certificate and would like to learn more about resources
What is the name of the middle school you attend?
What is the name of the high school you attend?
What is the name of the College/University you attend?
Where are you currently enrolled?
What year did you graduate or will you be graduating High School?
Please enter the 4 digit year. If you did not graduate high school please put NA.
How did you learn about Graduate 313?
Please select...
A community based organization
A community event
CHAMPions Ambassador Adult Learner
CHAMPions Ambassador College
CHAMPions Ambassadors High School
DPSCD Staff
My high school counselor
Program Advisors
Referred to by someone
Social Media post
Other
Please enter that individuals name.
Are you a participant in any of the following youth development organizations or after-school programs? (Select all that apply)
Atlantic Impact
College Career Beyond - Midnight Golf
Detroit Food Academy
Detroit Horse Power
Detroit Phoenix Center
Detroit Promise
Detroit Regional Chambers
Detroit Regional Dollars for Scholars
Developing K.I.D.S.
FATE Program
Hazel Park Promise Zone
Hope Ignites Detroit
Junior Achievement of Southeast MI
Mercy Education
Michigan Hispanic Collective
None of the above
Oakland 80
PrepandMe
Racquet Up Detroit
SAY Detroit Play Center
UPrep Schools
Urban Alliance
Urban Neighborhood Initiatives
Wayne RESA
Winning Futures
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Contact Information