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Date of birth:

Current year in school: --------- 7th 8th 9th 10th 11th 12th

School name:

Ethnicity: --------- Caucasian Hispanic Afro-American Asian/Pacific Islander Other

Gender: --------- Female Male

Where did you hear about our program: --------- Cal Poly website Engineering Camp website Cal Poly visit to classroom or school Visit to Cal Poly campus Email from Cal Poly Cal Poly employee Friend Poster/Flyer/Brochure Other

Need housing: --------- Yes No Maybe