It Takes A Village Academy GSRP Pre-Screen Form
Date of Birth *
MM
/
DD
/
YYYY
Sex *
Child's Name *
Address *
City *
Zip Code *
Phone Number *
Alternative Phone Number
Email Address *
Parent/Guardian's Name 1 *
Parent/Guardian's Name 2
Number of ALL (self, children, and other adults) household members for which you are financially responsible *
Gross Income *
Pay Frequency *
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