100 BMOJ ACT Bootcamp

Tell us a little about yourself!

ALL REQUIRED FIELDS MUST BE FILLED OUT

We will not share or sell your information.

This information is required in order to participate.

STUDENT First name

STUDENT Last name

Phone

Alternate Phone

Last 4 of SSN

Multi-line address

Country/Region

Address

City

Zip / Postal code

County (Hinds, Rankin, Madison, etc.)

STUDENT Birthday

Month

Day

Year

STUDENT Age

PARENT/Guardian Name(s)

School Name

Current Grade

Anticipated Graduating Year

Gender

Female

Male

Ethnicity

Hispanic or Latino

Non-Hispanic or Latino

Are you currently employed?

Yes

Highest Grade Completed

Are you a SNAP/TANF Recipient?

Yes

Have you taken the ACT Before?

Yes

If Yes, When did you take the ACT?

What was your score?

What are you trying to achieve with this bootcamp?

Are you a current or former mentee with 100BMOJ?

Yes

As a condition of participation we require students report their pre and post test score information.

Please check if you agree:

Yes

Yes, subscribe me to your email.