Access Student Intake Form (2025 - 2026)
First Name
Preferred First Name
Middle Name
Last Name
What is your preferred language:
Phone Number
Your Cell Phone Number
Email Address (non-school related)
email@email.com
x
High School Info
High School Name
Type "Other High School" if your school is not our list.
What is the name of your school?
What part of the Bay Area is your school in?
Please select...
Contra Costa
Lake County
Marin
Napa County
San Mateo
Santa Clara
SF Region
Sonoma
South Bay
Other
Current Grade
Please select...
12th Grade (Senior)
11th Grade (Junior)
10th Grade (Sophomore)
Graduation Year
Please select...
2026
2027
2028
High School Account ID
Owner ID
HS Geographic Area
Owner Email
Demographic Information
Birthdate
Please format the date as MM/DD/YYYY.
Gender
Please select...
Male
Female
Trans Woman
Trans Man
Gender non-conforming/non-binary
Prefer not to state/other
Gender Pronouns
Please select...
He/Him/His
She/Her/Hers
They/Them/Theirs
Other or Prefer not to state
What are your gender pronouns? (Optional)
Ethnicity
Please select...
American Indian/Indigenous American or Alaska Native
Asian
Black/African American
Hispanic/Latino/a/x
Middle Eastern/North African
Pacific Islander
White
Multiracial/Multiethnic
Not listed /prefer to self-describe
If you would like to indicate your tribal affiliation, please do so here.
Burmese
Cambodian
Chinese
Hmong
Indian
Indonesian
Japanese
Filipino
Korean
Laotian
Malaysian
Mien
Pakistani
Taiwanese
Thai
Tibetan
Vietnamese
Not listed
African
African American
Afro-Caribbean
Afro-Latino
Not listed
Argentinean
Bolivian
Brazilian
Chilean
Colombian
Costa Rican
Cuban
Dominican
Ecuadorian
Guatemalan
Honduran
Mexican/Chicano
Nicaraguan
Panamanian
Peruvian
Puerto Rican
Salvadoran
Spanish
Venezuelan
Not listed
Assyrian, Syriac or Chaldean
Egyptian
Iranian or Persian
Iraqi
Israeli
Jordanian
Lebanese
Moroccan
Palestinian
Syrian
Turkish
Other Middle Eastern
Not listed
Chamorro
Fijian
Native Hawaiian
Samoan
Tongan
Not listed
European
Not Listed
American Indian or Alaska Native
Asian
Black/African American
Hispanic/Latino/a/x
Pacific Islander
White
Multi-racial
Not listed
Please describe your ethnicity.
Please select all that apply:
I am or have been in Foster Care
I am or have been homeless
I (or my sibling) am the first in my family to plan to/attend college in the U.S.
I have lived in California for less than 3 years
Please estimate your combined household income in 2024:
Please select...
$0 - $20,000
$20,001 - $40,000
$40,001 - $60,000
$60,001 - $80,000
$80,001 - $100,000
$100,001 - $120,000
$120,001 - $140,000
$140,001 - $160,000
$160,001 - $180,000
$180,001 - $200,000
$200,001 +
I don't know
How much did your parents make in 2024.
Household size
Includes yourself, your biological or adoptive parents, and siblings (typically under 24) or other dependents for whom your parents provide more than 50% financial support.
x
Are you part of any of the programs below:
Academic Talent Search
AVID - 12th grade
Boys and Girls Club
Breakthrough Silicon Valley
Bridge The Gap
Cal-SOAP San Jose Consortium
Canal Alliance - College Readiness
College Is Real
COMPASS
Destination College Advising Corps (DCAC)
EAOP
Education Talent Search (Upward Bound)
Enterprise for Youth
Evergreen Valley College TRIO Talent Search
HeadsUp
Huckleberry
JCYC - Educational Talent Search (JCYC ETS)
JCYC - San Francisco College Access Center (SFCAC)
JCYC - Upward Bound (JCYC UB)
Latino Education Advancement Foundation (LEAF)
Pivotal
San Jose Aspires (SJ Aspires)
Senior Seminar - SFUSD
Students Rising Above
Summer Search
TRIO - Upward Bound (Sonoma County)
TRIO Talent Search
uAspire
UCSF EAOP
USF Educational Talent Search (USF ETS)
YMCA
Other
The Summit
Would you like to attend a college tour with 10,000 Degrees this summer?
Yes
No
Maybe
Parent/Guardian Information
Parent/Guardian First Name
Parent/Guardian Last Name
His/Her/Their email address
Please confirm his/her/their email
His/Her/Their phone number
How is this person related to you?
Parent
Stepparent
Foster Parent
Legal Guardian
Grandparent
Sibling
Aunt
Uncle
Other
Please write how this person is related to you.
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