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BTO Participant Registration
Data Collection
Email *
First Name *
Last Name *
Pittsburgh Public School ID Number
Street Address *
City *
State *
Zipcode *
Your phone number *
Your email *
Your Birth Date *
MM
/
DD
/
YYYY
Gender Identity *
Preferred Pronouns *
Ethnicity *
Required
Name of the school you're attending this year *
Grade your currently in *
Are you a part of the free lunch program at your school? *
Name of the school you attended last year *
Language Spoken at Home *
Parent/Guardian #1 First Name *
Parent/Guardian #1 Last Name *
Is this person your emergency contact? *
Head of Household *
Single Family Home *
Number of children under 18 living in home *
Relationship *
Cell Phone *
Home Phone *
Email
Parent/Guardian #2 First Name
Parent/Guardian #2 Last Name
Relationship #2
Clear selection
Cell Phone #2
Home Phone #2
Email #2
Additional Emergency Contact NAME (if different from above)
Additional Emergency Contact PHONE NUMBER (if different from above)
Are there any people that are not permitted to pick you up?
Are you permitted to walk home? *
Do you have any of the following health conditions? (Check all that apply) *
Required
Are you taking any medications? *
If you answered yes, please list the medications you currently take.
Please list any medication allergies that you have. If you don't have any, write none. *
Please list any food allergies that you have. If you don't have any, write none. *
Please list any general allergies that you have. If you don't have any, write none. *
Do you like to participate in physical activities? *
Do you have any of the following? *
Required
Do you currently receive counseling services here or anywhere else? *
Are you interested in receiving counseling services? *
Do you permit BTO staff/interns/volunteer to take your photo? Most photos do not include your face or other identifiable traits unless you and your parents have signed written consent. *
Can we use these image in social media posts and on our website? Again, We make every effort to not include your face or other identifiable traits for your safety. *
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