Name:* Date:

Address:*

City:*

State: * Zip Code:*

Home Phone number:

Cell Phone number:

What grade are you in?*

You presently live with?*
Parents Guardian Yourself Other

Where are you today?*
College Trade School Full Time work Military Other

Do you work now?*
No Yes

If yes, do you work
Full Time Part Time

If no, where do you look for work?
School Computer Family/Friends Radio/TV Newspaper/magazine