United We Can Registration Form
Student's last name *
Your answer
Student's first name *
Your answer
Date of birth *
MM
/
DD
/
YYYY
Gender *
Race & Ethnicity *
Parent / Guardian name (full name) *
Your answer
Address (please provide a complete address) *
Your answer
Primary phone number *
Your answer
Secondary phone number
Your answer
Email
Your answer
Preferred language *
Preferred method of communication *
What grade level is the student currently in? *
What school does the student currently attend? *
What middle school will the student be attending? *
Is the student on an IEP (Individualized Educational Plan)? *
Is the student in ELL classes (English Language Learner)?
Will the student be attending TPS summer school? *
Are you interested in enrolling your student into United We Can's 2019 Summer Academy? *
Has the student had conduct issues (detention, suspension etc.)? *
Never
Always
Is the student enrolled in other programs (Day Spring, Camp Fire, etc)? *
Does your child have a sickness or special condition that we should be aware of (for example, allergies, diet restrictions, seizures)?
Your answer
Is there an existing family situation that we should be aware of?
Your answer
How did you hear about United We Can? Please provide as much detail as possible. *
Your answer
Who were you referred by?
Your answer
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