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Please fill out the form below to take the first step toward being successful in school.
Student Name *
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Date of Birth *
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Email (Student) *
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Email (Parent) *
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Street Address, Town, State, Zip Code *
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Cell Phone Number (Parent) *
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Home Phone Number (Parent) *
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Cell Phone number (Student) *
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Attending School *
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Current Grade *
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Do you receive free or reduced price school lunch? *
Services Interested In *
After-school (Monday-Thursday)
Saturday Morning
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College Placement Test Prep (ACCUPLACER)
College Application Essay Assistance
FAFSA Application Assistance
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By submitting this form I confirm that I am at least 18 years of age, and provide my written consent for Million Reasons to contact me/my child using email or telephone and provide academic enrichment services to my child/children. I understand that only those receiving free or reduce price school lunch is eligible to receive the free services of Million Reasons and that submission of appropriate documents are required to be accepted to the programs. *
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Name of Parent/Guardian: *
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Signature: *
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