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Boston Breaking Movement - Breakdance Mentorship Program Application Form 2017
Application for Summer 2017 Breakdance Mentorship Program - Organized by Boston Breaking Movement, in affiliation with Dorchester Youth Collaborative
Student Name:
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Student Birth Date: (MM/DD/YY)
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Student Gender:
Student Home Address: (Street Address, Town/City, State, Zip Code)
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Student Home Phone:
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School Name:
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Grade:
Parent / Guardian / Primary Contact Name:
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Home Address: (If different from student address)
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Phone Number: (If different from student phone)
Your answer
Preferred Method of Contact for Primary Contact:
Emergency Contact #1 Name:
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Emergency Contact #1 Phone:
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Emergency Contact #1 Relationship to Student:
Your answer
Emergency Contact #2 Name:
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Emergency Contact #2 Phone:
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Emergency Contact #2 Relationship to Student:
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Is your child currently treated for any injury or sickness, or taking any form of medication for any reason? If yes, please explain.
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Is your child allergic to any type of food or medication? If yes, please explain.
Your answer
Are there any conditions regarding the student of which we should be aware? If yes, please explain.
Your answer
Are you interested in applying for financial aid? (A separate form will be given on request)
Student Ethnicity (optional): Knowing the demographic makeup of our students may assist with grant writing, outreach, and more!
Do you identify as Hispanic? (optional)
Family Income (optional): Knowing the demographic makeup of our students may assist with grant writing, outreach, and more!
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