Strive Application - Central Oregon Community College

Name (First and Last): *

Birthday (MM/DD/YYYY)*

Mailing Address:*

City*

State*

ZIP Code*

Home phone:

Cell phone:

Email:

Names and phone number of Parents/Guardians:*

What is the best way to contact you?*(Phone, email, parent’s phone, grandma’s phone, etc.)

Do you have access to the internet?

Yes

No

There’s a nearby space where I can regularly go for internet

Do you have access to a computer?

Yes

No

I can borrow or access one regularly

Name of school you are attending: *

Current grade level in school:

Year you expect to graduate from High School:*

Current GPA(this will not affect your acceptance to STRIVE)

Tribal Affiliation:

T-shirt size:

3XL

2XL

XL

Large

Medium

Small

Have you been to STRIVE before?

Yes

No

Gender Identity and preferred pronouns: *

What to you hope to gain by attending STRIVE? *