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Email *
Student's Full Name *
Date of Birth *
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Email (Student)
Email (Parent)
Street Address *
Town *
State, Zip Code *
Cell Phone Number (Parent) *
Home Phone Number (Parent)
Cell Phone number (Student)
Name of the School Student Attends *
GRADE ENTERING IN SEPTEMBER *
Required
Do you receive free or reduced price school lunch? *
Services Interested In (September -June)
Monday-Friday 3:30pm- 5:30pm
Saturday 10:00am-12:00pm
Tutoring- Math
Tutoring - English
Tutoring - Other Academic Subjects
Test Prep (PSAT/SAT/ACT/ACCUPLACER)
Services Interested In (September -June)
Friday 4:30pm- 5:30pm
Girls for STEM
Where did you hear about this program? *
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 I have to send the appropriate documents to Million Reasons to be accepted to the free programs. *
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Name of Parent/Guardian: *
Parent's Signature *
Date *
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