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APPLICATION FOR REACH MEMBERSHIP
Your answers on this form will be viewed by REACH Board members. Some information, such as name, address, children’s names, ages and curriculum will be made available to REACH in the form of our membership directory. Should you have any questions or need help with this form, contact membershipreachboard@gmail.com .
About You and Your Family
Type of Application *
Father First Name
If living in the household.
Your answer
Father Last Name
If living in the household.
Your answer
Father Occupation
If living in the household.
Your answer
Mother First Name
If living in the household.
Your answer
Mother Last Name
If living in the household.
Your answer
Mother Occupation
If living in the household.
Your answer
Address *
House Number and Street Name Line (i.e. 578 Main Street)
Your answer
City, State, Zip *
City, State and Zip Code Line (i.e. Russellville, AR 72801)
Your answer
Home Phone
(i.e. 479-967-1234)
Your answer
Cell Phone
(i.e. 479-967-5678)
Your answer
Email *
Your answer
Emergency Contact *
List Name, Phone Number, and Relationship (i.e. Jane Jones 479-567-1234 Grandmother)
Your answer
Church Affiliation
Your answer
Children
Disciplinary Action *
Were any of your children under disciplinary action at their previous school?
Disciplinary Explanation
If Yes, please explain.
Your answer
Special Needs
Do any of your homeschooled children have special needs?
Special Needs Explanation
If Yes, please explain. This information would be helpful as we try to encourage and support you through our mentor match program.
Your answer
List children NOT in the home.
(optional)
Your answer
Information on Children in the home.
There are enough fields to enter eight (8) children. If you have more than eight (8) children living in the home, please enter the school aged children you are homeschooling first. There will be a text box after the 8th child where you can list additional children in the home and their ages.
Child 1 Name *
FIRST and LAST NAME
Your answer
Child 1 Sex *
Child 1 Age *
In Years as of August 1. If under 1, list as 0.
Your answer
Child 1 Birth Date *
MM
/
DD
/
YYYY
Child 1 Type of School *
(for the coming year for this child in particular)
Child 1 Grade *
Per this child's Intent to Home School for the upcoming year
Child 1 Last Attended *
In order for us to best assist families who are transitioning from other schooling methods to homeschooling, please indicate this child's previous school year experience.
Have another child at home to list? *
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