GANAS Application Form - Central Oregon Community College

Name (First and Last): *

Birthday (MM/DD/YYYY):*

Home or Mailing Address:*

City:*

State:*

ZIP Code:*

Phone Number:*

Email:*Enter your personal email address

Languages you speak (fluently or not):*

Language(s) primarily spoken in your home: *

Parents/guardians who will drop you off or pick you up after program & phone number: *

Name of the high school you are attending: *

Current grade level in high school: *

Year you expect to graduate from high school:*

What is your current GPA:*

If you graduated this year, please list the college you plan on attending in the fall:*

Which option best describes you?

Woman

Man

Non-binary

Prefer not to say

Other

If you selected other, please explain:

Pronouns:*She/Her, He/Him, They/Them, etc.

Is your gender identity the same as the sex you were assigned at birth?

Yes

No

T-shirt Size:

Small

Medium

Large

X-Large

2X-Large

Did you previous attend the GANAS Program?

Yes

No

If returning, why do you want to return to the GANAS Program?

To best support your needs, how would you prefer to receive GANAS registration materials?

Email (electronic copies)

Mail (printed packet)

Please list any dietary sensitivities:

What do you hope to gain by attending COCC's GANAS Program?*

What are your goals for after high school?*

Please discuss what things you are currently doing at your high school and/or community?*