Genesis Parent Portal Request
The completion of this form will grant parent or guardian(s) listed access to the student's Genesis account once it is approved.
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Student Name *
School Name *
Student Birthdate *
MM
/
DD
/
YYYY
Student Home Address *
Genesis Parent/Guardian 1 Name *
Genesis Parent/Guardian 1 Current Phone Number *
Genesis Parent/Guardian 1 Email Address *
Genesis Parent/Guardian 2 Name
Genesis Parent Guardian 2 Current Phone Number
Genesis Parent Guardian 2 Email Address:
Does this student have siblings who attend other schools in Orange?  If yes, please list each sibling and the school they attend in the area provided below. *
Sibling Name  #1 and the School Name
Sibling Name #2 and the School Name
Sibling Name #3 and the School Name
Sibling Name #4 and the School Name
Sibling Name #5 and the School Name
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