West Charlotte - E2D Signup
Student Name (Last, First) *
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Student ID Number: *
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Parent/Guardian Name (Last, First): *
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Parent/Guardian E-mail: *
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Phone Number: *
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Physical Address: *
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Mailing Address (if different)
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School: *
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Student Grade (2016-17) *
CIS (Communities IN Schools) Program Participant?
Family Ethnicity *
Language of Preference *
Is a Translator Required? *
Does Student have Internet Connectivity at Home?
Submitted by (put in the name of staff member you have corresponded with)
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