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The University of Texas at Austin
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UT YEC Intake Form
Our mission is to enrich the educational and professional pursuits of under-represented students through intentional programming, experiences, and relationships designed to grow leaders who will change the world through fulfilling individual purposes. We would love for you to be a part of our program, where the focus is on college access and success, mentoring, professional development, travel/study abroad, and internships.
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required
field
Student Information
Student First Name*
Preferred First Name
Student Last Name*
Birthdate*
Birthdate*
January
February
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1911
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1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
Gender
Female
Male
Prefer to self-describe
Please describe:
Are you Hispanic or Latino?
Yes
No
Please indicate how you identify yourself. Select as many as apply.
Please indicate how you identify yourself. Select as many as apply.
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
Student Contact Information
Student Email Address*
Primary Phone Number
Mobile Phone Number
Mailing Address*
Mailing Address*
Country
Street
City
Region
Postal Code
Best Contact Method
Home Phone
Mobile Phone
Email
Which UT Youth Engagement Center do you wish to register for?
Austin
Dallas
Houston
RGV
San Antonio
High School Name
School Code
High School Class of
My current high school class rank is:
Top 5%
Top 10%
Top Quarter
Second Quarter
Third Quarter
Fourth Quarter
I don't know my rank.
My school does not rank.
Student ID
Currently Employed
Career Interests
Living at Home Status
Living at Home Status
At Home with Parents
Living with Other Family Members
Living with Friends
Potential Majors
Predominant Language
Predominant Language
English
Spanish
Other
Language:
High School Grade
High School Grade
Senior
Junior
Sophomore
Freshman
Citizenship
DACA
Permanent Resident
US Citizen
Undocumented
United States
Are you in AVID?
Are you in AVID?
Yes
No
Do you participate in the Free or Reduced Lunch Program?
Do you participate in the Free or Reduced Lunch Program?
Yes
No
Are you First Generation?
Are you First Generation?
First Generation
Not First Generation
Are you interested in receiving more information about UT Austin Admissions?
Are you interested in receiving more information about UT Austin Admissions?
Yes
No
I plan to apply to UT Austin for:
Spring 2022
Summer 2022
Fall 2022
Spring 2023
Summer 2023
Fall 2023
Spring 2024
Summer 2024
Fall 2024
I plan to apply to college as a:
Freshman
Transfer
Parent/Guardian 1 Address same as Student Address?
Parent/Guardian 1 Address same as Student Address?
Yes
No
Parent/Guardian 1 Email
Parent/Guardian 1 First Name
Parent/Guardian 1 Last Name
Parent/Guardian 1 Relation
Father
Mother
Step-Father
Step-Mother
Legal Guardian
Parent/Guardian 1 Address
Parent/Guardian 1 Address
Country
Street
City
Region
Postal Code
Parent/Guardian 1 Highest Grade Completed
Parent/Guardian 2 Address same as Student Address?
Parent/Guardian 2 Address same as Student Address?
Yes
No
Parent/Guardian 2 Email
Parent/Guardian 2 First Name
Parent/Guardian 2 Last Name
Parent/Guardian 2 Relation
Father
Mother
Step-Father
Step-Mother
Legal Guardian
Parent/Guardian 2 Address
Parent/Guardian 2 Address
Country
Street
City
Region
Postal Code
Parent/Guardian 2 Highest Grade Completed
By checking the "I agree" box below and submitting the form, I (the parent/guardian of the student listed above) am authorizing the sharing of this information with the University of Texas at Austin. I also authorize my student to participate in the program. This checkbox is my signature as a parent/guardian
By checking the "I agree" box below and submitting the form, I (the parent/guardian of the student listed above) am authorizing the sharing of this information with the University of Texas at Austin. I also authorize my student to participate in the program. This checkbox is my signature as a parent/guardian
I agree
I do not agree
Please feel free to reach out to us with any question at
yecdallas@austin.utexas.edu
Submit