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About You and Your Household

Please fill in the following items to the best of your ability. Note: items with a * are required.

First Name *  
Middle Initial
Last Name *  
Street Address
Zip Code
Phone Number
Best phone number to contact you at in 5 years
Your Date of Birth *  
Your Gender *  
What grade are you in this school year? *  
Your Email Address
Confirm Your Email Address  
What is the primary language spoken in your home? (select one)

What best describes your racial and ethnic identity? (select all that apply)?

Living arrangements--you live...
Please choose a security question and answer so you can retrieve your answers at a later time.
Security Question *
Security Question Answer *  

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