Foothills Registration Survey
Have you attended Foothills or Mountain Education Charter HS before?
If yes, what was the last month you attended?
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DD
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YYYY
Which Foothills site do you plan to attend? *
Student First Name (required) *
Your answer
Student Middle Name
Your answer
Student Last Name (required) *
Your answer
Maiden Name
Your answer
Sex (required) *
Date of Birth (required) *
MM
/
DD
/
YYYY
City of Birth (required) *
Your answer
State or Nation of Birth (required) *
Your answer
Home Street Address or Post Office Box (required) *
Your answer
City (required) *
Your answer
State (required) *
Your answer
Zip Code (required) *
Your answer
Student Cell Phone
Your answer
Home Phone (required - if no home phone, re-enter cell phone *
Your answer
Student Email Address (required, if no email, enter noemail@gmail.com) *
Your answer
Are you Hispanic/Latino? (required) *
Race/Ethnicity (required. check all that apply, must check at least one) *
Required
Mother's First Name
Your answer
Mother's Last Name
Your answer
Mother's Phone
Your answer
Mother's Email
Your answer
Father's First name
Your answer
Father's Last Name
Your answer
Father's Phone
Your answer
Father's Email
Your answer
With whom do you live? (required) *
Other Contact First Name
Your answer
Other Contact Last Name
Your answer
Other Contact Phone Number
Your answer
Other Contact Email Address
Your answer
Do you take any medication(s) while at school? (required) *
List Medications Taken
Your answer
Emergency Contact Name (required) *
Your answer
Emergency Contact Phone (required) *
Your answer
Are you employed? (required) *
If yes, list place of employment.
Your answer
Employer Phone
Your answer
Do you have children?
If yes, how many.
Your answer
Do you have allergies? (required) *
If yes, what are you allergic to?
Your answer
Are you diabetic? (required) *
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