Impact 2020

Student Name*

Student Email School Name

Birth Date (MM/DD/YYYY)
Grade in 2020-2021:*
Home Address*
Street Address

City State ZIP / Postal Code Student Phone Number
Parent Name*

Parent Email Parent Phone

For educational and funding reporting purposes, Close Up requests that you provide the following demographic information. Such information will remain confidential and will not be used at any time for selection or placement criteria for the Close Up programs. Please complete all items below. Your cooperation is greatly appreciated.

1. Are you are a member of a farm/migrant community:

2. Which best describes your school district?

3. Check here if you are Hispanic or Latino:

4. Which best describes you? (please select one or more):

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

5. Check here if you are a citizen of the United States:

I have read and agree to the Terms and Conditions: Parent Initials Student Initials