PARTICIPANT INFORMATION AND DEMOGRAPHIC FORM

First Name: _______________________________________ Middle Initial: _________________

Last Name: ____________________________________ Date of Birth: _____/______/________

Street Address: ________________________________________________________________

City: ____________________________________ Zip Code: __________________________

Home Phone: ___________________________ Cell Phone: ____________________________

School Name: _____________________________________ Current Grade: ______________

Race / Ethnicity: Please check box below (choose one)

African-American	Other Black (specify below)
Asian: Chinese	Asian: Filipino
Asian: Indian	Asian: Japanese
Asian: Korean	Asian: Laotian
Asian: Thai	Asian: Vietnamese
Asian: Other (specify below)	Hispanic/Latino: Mexican
Hispanic/Latino: Central American	Hispanic/Latino: South American
Hispanic/Latino: Caribbean	Hispanic/Latino: Other (specify below)
Middle Eastern (specify below)	Native American
Pacific Islander: Guamanian	Pacific Islander: Tongan
Pacific Islander: Samoan	Pacific Islander: Other (specify below)
White	Multiracial/Multiethnic (specify below)
Other (specify below)	Decline to State

Specify Ethnicity: _______________________________________________________________

Language spoken at home: _______________________________________________________

English Fluent? (circle one): YES NO Gender (circle one): MALE FEMALE

Household Type (circle one): Single Female Single Male Dual Headed

Household size (how many people live in your house?): ______________________

Household Income (choose one)

Extremely Low	Low
Moderate	Above Moderate

Parent / Guardian Name(s): _______________________________________________________

Work Phone: ____________________________ Home/Cell Phone: _______________________

Best time parent /guardian can be reached: __________________________________________