Student Email Address Verification
This is a form to assist the AHS counselors in collecting ELC eligible information to sent to the UC School System.  This email address will be used by the UC System to contact students about their ELC status and to promote the University of California university information.  Only students who have been identified and were given an authorization form should fill out this survey.  

PLEASE BE SURE TO PUT YOUR EMAIL ADDRESS INTO THIS SURVEY

PLEASE BE SURE TO SUBMIT YOUR DATE OF BIRTH EXACTLY AS INSTRUCTED:  
For Date of Birth, BE SURE TO HAVE A TOTAL OF 8 DIGITS:  MM/DD/YYYY with  slashes,.  TWO DIGITS FOR MONTH AND TWO DIGITS FOR THE DAY.   EXAMPLE:  If you were born in March, then MARCH IS "03"  AND if you were born on the first of March, then THE FIRST OF THE MONTH IS "01" .  This would be correct:  03/01/1999 for March 1st, 1999

Thank you.  
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What is your first name? *
Be sure to spell correctly and capitalize the first letter
What is your MIDDLE Name?  If none, leave blank
Be sure to spell correctly and capitalize the first letter
What is you last name? *
Be sure to spell correctly and capitalize the first letter.
What is your street address?
Example:  1122 Boogie Boogie Avenue, Unit 12
What is city that you live in? *
Example:  Fremont
What is your zip code?
What is your date of birth?  READ INSTRUCTIONS BELOW *
BE SURE TO HAVE A TOTAL OF 08 DIGITS:  MM/DD/YYYY with a slash in between the day, the month, and the year.  TWO DIGITS FOR MONTH AND TWO DIGITS FOR THE DAY.   EXAMPLE:  If you were born in March, then MARCH IS "03"  AND if you were born on the first of March, then THE FIRST OF THE MONTH IS "01" .  (03/01/1999)
What is your date of birth?  READ INSTRUCTIONS BELOW *
BE SURE TO HAVE A TOTAL OF 08 DIGITS:  MM/DD/YYYY with a slash in between the day, the month, and the year.  TWO DIGITS FOR MONTH AND TWO DIGITS FOR THE DAY.   EXAMPLE:  If you were born in March, then MARCH IS "03"  AND if you were born on the first of March, then THE FIRST OF THE MONTH IS "01" .  (03/01/1999)
We need your email address!  What is your email address that you would like the University of California to use for contacting you? *
Student, what is your AHS ID number?   *
Be sure to have no spaces before or after the ID number.
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