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Gender

Male

Female

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone *

(###)

###

####

Cell Phone *

(###)

###

####

Birthdate *

MM

DD

YYYY

Foster Care? *

Currently

In the Past

N/A

Transportation *

Yes

No

Are you Hispanic/Latino? *

Yes

No

Race (Choose One) *

White

Asian

African-American

Multiracial

Native American

Pacific Islander

Home/Cell Phone *

(###)

###

####

Work Phone *

(###)

###

####

Home/Cell Phone *

(###)

###

####

Work Phone *

(###)

###

####

Have you ever been expelled? *

Yes

No

Have you ever been charged of a Felony? *

Yes

No

Have you been convicted or adjudicated for a CSC? *

Yes

No

Do you live with your parents? *

Yes

No

Is English spoken in your home? *

Yes

No

Have you ever received special educational services *

Yes

No

I give this student permission to take over-the-counter individually packeged medications for minor ailments while at school.

Yes

No

Date

MM

DD

YYYY