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
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Hispanic or Latino
Not Hispanic or Latino
Race
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American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Two or more races
General Information
What category best fits your needs?
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Middle School Student
High School Student
Traditional College Student
Adult Learner (Obtaining GED, HS Diploma, Certificate Pathway, Post Secondary Degree, Transitioning jobs or career fields)
Which statement do you most identify with?
Please select...
I am a middle/high school student who wants help in figuring out my post-secondary (college or trade school) goals
I am a current college/trade school student who would like to learn more about resources
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
I know someone who fits into one of these categories
What level of school are you attending currently?
Please select...
Middle School
High School
College/University
None of the above
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?
Please list your Place of Employment.
Have you been contacted by a Graduate 313 Program Advisor?
Please select...
Yes
No
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.
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Contact Information