Student Information Form

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Student's full name *

Birthdate *

YYYY

Gender *

Male

Female

Prefer not to say

Grade *

9th

10th

11th

12th

Hispanic or Latino ethnicity *

Yes

Race *

American Indian or Alaska Native (A person having origins in any. of the original peoples of North and South America, including Central America, and Who maintains tribal affiliation or community attachment.)

Asian (A person having origins in any of the original peoples of Far East, Southeast Asia, or the Indian subcontinent, including for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam)

Black or African American (A person having origins in any of the black racial groups of Africa)

Native Hawaiian or Other Pacific Islander (A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands)

White (A person having origins in any of the original peoples of Europe, Middle East, or North Africa)

Other:

Language Spoken at Home *

Student Physical/911 Address *

Student Mailing Address *

Student Phone Number *

Parent/Guardian #1 Name *

Parent/Guardian #1 Relationship to Student
*

Parent/Guardian #1 Language of Correspondence
*

Parent/Guardian #1 Mailing Address
*

Parent/Guardian #1email address
*

Parent/Guardian #1 Phone number
*

Parent/Guardian #1 Employer
*

Does student primarily reside with Parent/Guardian #1 ? *

Yes

Parent/Guardian #2 Name
*

Parent/Guardian #2 Relationship to student
*

Parent/Guardian #2 Language of correspondence
*

Parent/Guardian #2 Mailing address
*

Parent/Guardian #2 email
*

Parent/Guardian #2 Phone number
*

Parent/Guardian #2 Employer
*

Does student primarily reside with Parent/Guardian #2?
*

Yes

Additional Guardian contact name *

Additional Guardian contact Relationship to student
*

Additional Guardian contact Language of correspondence
*

Additional Guardian contact mailing address
*

Additional Guardian contact email
*

Additional Guardian contact employer
*

Does the student primarily reside with this guardian?
*

Yes

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