Class Climate online-survey - ECTC Student Hub Intake Survey

1Student Information

1.1

Student ID:

Question Student ID:

1.2 First Name:

1.3 Last Name:

1.4 Street Address:

1.5 City:

1.6

State:

Question State:

1.7

Zip Code:

Question Zip Code:

1.8

Phone Number:

(

Question Phone Number:

)

Question Phone Number:

1.9 Student Email:

1.10Ethnicity:

1.11Gender Identity:

2Student Support Services Referral

2.1Are you a first-generation college student?

Yes Question Are you a first-generation college student?

No Question Are you a first-generation college student?

2.2Are you Pell eligible?

Yes Question Are you Pell eligible?

No Question Are you Pell eligible?

2.3How would you like The Hub to enrich your life?

2.4How did you hear about The Hub?

2.5 Please specify:

2.6 Please type your full name and date in the box below verifying the information you have provided is updated and correct to the best of your knowledge.

2.7

Question

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Question