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PARENT /GUARDIAN INFORMATION
Name
*
First
Last
M.I.
MM slash DD slash YYYY
Street Address
*
Apartment/Unit #
*
City
*
State
*
ZIP
*
Home Phone
*
Cell Phone
School
Grade
Grade
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Age
Email Address
Is this for a student?
Yes
No
Gender
Male
Female
Is this for volunteering opportunities
Yes
No
What area are you interested in
Are you interested in supporting the program financially
Yes
No
One time donation or monthly
WHAT SIDE OF TOWN DO YOU LIVE?
*
Northside
Southside
Eastside
Westside
Other
YOUTH INFORMATION
Please list all students you would like to enroll
Full Name
Age
Grade
Grade
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Race
Race
Black or African American
Hispanic or Latino American
Asian American
White or European American
Native Americans and Alaska Natives
Other Race or Multiracial American
School
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Full Name
Age
Grade
Grade
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Race
Race
Black or African American
Hispanic or Latino American
Asian American
White or European American
Native Americans and Alaska Natives
Other Race or Multiracial American
School
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Full Name
Age
Grade
Grade
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Race
Race
Black or African American
Hispanic or Latino American
Asian American
White or European American
Native Americans and Alaska Natives
Other Race or Multiracial American
School
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
PARENT/GUARDIAN SIGNATURE
Signature
Date
MM slash DD slash YYYY
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