Year Up Student Interest Form

AdmissionS PROCESS

Connect with Year Up:

* Required field

Yes, I am interested in learning more about applying to Year Up.
Select a site: Atlanta Boston Chicago New York City Providence San Francisco Bay Area National Capital Region
Is this your first time contacting Year Up? *
	yes no
If no, please explain:

If you have attended Year Up before, please specify when:

Desired entry date:
Background:
First name	*
Middle name
Last name	*
Maiden/Former name
Address	*
Apartment #
City	*
State	*
Zip	*
Home phone	*
Work phone
Cell Phone/Pager
Email (if have one)
Birth Date	* (MM-DD-YY)
Age	*
Gender	Male Female *
If you wish to be identified as a member of any of the following groups, please check one
Asian or Pacific Islander Native American Black, non-Hispanic White, non-Hispanic Hispanic Other, what?
Education:
Have you received or will you receive any of the following diplomas? *
High School (HS) GED Certificate Neither
What is the name of your high school or GED program? *
When is your graduation date? (MM-DD-YY)
Have you taken any college classes?	Yes No
Do you have an associate's degree or a college degree?	Yes No
Income:
Estimated Personal Income per year
Estimated Household Income per year
Other:
Do you have a legal right to work in the U.S.?(see below for a list of required documents) *	Yes No
To answer "yes" above, you must have: One of these documents Us Passport, Or Permanent Resident card, OR Certificate of US Citizenship, OR Certificate of Naturalization OR Two of these documents Official Picture ID AND US Social Security Card, OR US Birth Certificate, OR US Citizen Card ID includes non-US passport, Driver's License, or State ID
Are you interested in any of the following fields?
IT (Computer Technical Support) Investment Operations (Financial Services) Neither
How did you hear about Year Up? (Check one) *
Year Up website Non-Year Up website College Radio Television Public Transportation Ad Church Job/College fair Presentation (Please specify where, e.g., high school) Newspaper/Magazine (Please specify) Word of mouth*** (Please specify below) Other (Please specify)
*** If you heard about Year Up through word of mouth, please specify below (Check all that apply)
Year Up Student (Last Name, First Name) Year Up Alumni (Last Name, First Name) Year Up Staff (Last Name, First Name) Other (Last Name, First Name)
Please specify if "Other" is your:	Guidance Counselor Teacher/Principal Social Worker Program staff Co-worker Friend or Family


Equal Opportunity: All applicants will be given equal consideration. No question on this form will be used to screen out or discriminate against any candidate. Year Up does not discriminate on the basis of race, color, national origin, disability, sex, age (except as necessary for the normal operation of the program or to meet a statutory objective), gender including gender identity, sexual orientation, religion, marital status, veteran status, or any other characteristic protected by law.

"When I felt that I wanted to drop out or give up, they would not let me. And that really caught my eye. Wow, people really care."

Michael Hurblin
Class of 2003

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