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6. Please indicate your ethnic / racial / cultural self-description (you may check more than one box). 

(Our federal grant requires that we report demographic information on our participants.  All responses are confidential; data will be reported only in aggregate.)

7. Do any of the following apply to you:
  • I come from a high school where less than half the graduates apply to college.  
  • At least 30% of the students at my high school were eligible for free or reduced lunch.  
  • English is not my primary language.  
  • Neither of my parents attended college.  
  • My parents' income is below  $40,321 for a family of 3; $48,601 for a family of 4; $56,881 for a family of 5; or $65,161 for a family of 6 (add $8,320 for each additional person in larger families). (200% of HHS poverty guidelines)

11. Are you currently (Spring 2017) enrolled in a college, university, or professional training program?

12. When do you expect to complete this program?

16. Have you previously participated in any Wisconsin AHEC programs? Please check all that apply.

17. Have you applied for Wisconsin Express before?

18. How did you learn about Wisconsin Express?

20. If selected, are you able to pay the $210 participation fee?

24.  Site preference.
Please indicate your community site preferences among the choices listed below.
All 12 sites are offered for May 21-26, 2017; please note that 3 sites are also offered during UW-Madison's Spring Break (March 19-24, 2017). If you wish to be considered for multiple program dates, you can indicate your preferences within one application (no need to apply twice). 

      Very most preferred site Strongly interested in a placement offer for this site Not interested / can not accept placement offer

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