subject_line
Prospect Sign Up
Register for Ready to Rise
Sign up to receive information and updates about Act Six.
Sign up to receive information and updates about Act Six.
Complete this form to receive information and updates
as Ready to Rise gears up this spring.
Complete this form to receive information and updates
as Ready to Rise gears up this spring.
Sign up to receive information and updates about Act Six + Ready to Rise.
Program Site (where you live)
*
Tacoma-Seattle
Portland-Salem
Clark County
Yakima Valley
Spokane
Minneapolis-St Paul
Chicago
Indianapolis
Email Address
*
FIRST Name
LAST Name
Primary Phone
Type
*
Mobile
Home
Other
Can we text you?
Text OK
Other Phone
Type
*
Mobile
Home
Other
Can we text you?
Text OK
Gender
Female
Male
Non-binary
Race + Ethnicity (mark all that apply)
American Indian
Asian
Black
Hispanic
Pacific Islander
White
High School
State
*
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Current High School (or the one you graduated from)
*
Other High School
*
🛈
Graduation Date
*
+
Cumulative GPA
Which program(s) are you interested in?
*
Act Six
Ready to Rise
Both
How likely are you to apply for the program?
4 Already Started
3 Very Likely
2 Somewhat Likely
1 Not Likely
How likely is it that you will attend a Ready to Rise partner college and enroll in the program this summer?
3 Very Likely
2 Somewhat Likely
1 Not Likely
Complete Mailing Address
City
State
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip
Do you participate in any of the following programs?
AVID
College 101
GEAR UP
TRIO
Upward Bound
Other
Other
Do you participate in any of the following programs?
APCC
ASPIRE
AVID
CSF
MESA
Peace CC
Talent Search
Upward Bound
Urban League
YMCA
Other
Other
Do you participate in any of the following programs?
AVID
CSF Achievers
GEAR UP
Talent Search
Upward Bound
YMCA
Other
Other
Referred By (Staff Only)
Event (Staff Only)
© 2020 Degrees of Change