First Name *

Last Name *

Identity (Father / Mother / Guardian, etc.) *

Adult Phone Number *

Adult Email Address *

Secondary Adult Information (Optional)

First Name

Last Name

Identity of Secondary Adult (Father / Mother / Guardian, etc.)

Adult #2 Mobile Phone Number

Adult #2 Email Address

Your Student Information:

Student Gender *

Male

Female

Non-Binary

First Name *

Middle Initial

Last Name *

Street Address (Primary Residence of Student) *

City *

State *

Zip Code *

Student Mobile Phone Number *

Student Email Address *

Student Date of Birth *

Race of Student: (Check all that apply) *

White

Black or African American

Asian

Native Hawaiian/Other Pacific Islander

Native American

Hispanic/Latino

Multiracial

Other

Is Your Student a First-Generation College Student? (Will the the first one in their family to go to college.) *

Yes

Student Grade Level *

Freshmen

Sophomore

Junior

Senior

Does your student qualify for Free-and-Reduced Lunch? *

Yes

Is your student part of any other identities you want to make sure we know about (ethnicity, first-language, sexual orientation, etc.)? If Yes, please write it in the box below.

Primary Adult (Additional Information)

Relationship to Student *

Highest level of education *

Preferred language *

Marital Status *

Single

Married

Separated

Family/Household Size *

Annual Family or Household Income *

Custody & Pickup

Legal Custody Arrangements/Restrictions (attach orders if applicable)

Approved Adults for Pickup (name, relationship, phone)

1
2
3

Emergency & Medical

Primary Emergency Contact (if not a parent above):

Name

Relationship

Phone

Physician/Clinic

Physician/Clinic Phone

Insurance Carrier

Policy/Member #

Allergies/Medical Conditions

Current Medications & Instructions

Parent Signature:

Signature *

Clear

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