High School Academic Support Registration
Dates and Times: 9/9/19-12/19/19 from 5:00-6:00pm
Address: 927 3rd St, Rosenberg TX 77471
Questions? 346-702-3806
Student Name *
Your answer
Age *
Your answer
Birth date
MM
/
DD
/
YYYY
Male or Female
Grade in school? *
School Name
Your answer
Parent Name *
Your answer
Address
Your answer
Cell Phone Number *
Your answer
Email:
Your answer
Emergency Contact Info
Name of Local Friend or Relative
Your answer
Relationship to Student
Cell Phone:
Your answer
Food Allergies
Dietary restrictions *
Your answer
By signing below, I give my permission to Fort Bend Hope to use either photographs or video recordings for publication and/or public relations efforts, such as newsletters, brochures, newspaper articles, website, displays, films, etc., both physical and virtual in format. *
Your answer
I hereby give permission for my child (above referenced) to participate in Fort Bend Hope’s After School Mentoring Program. I agree to return any books and/or materials to Fort Bend Hope that my child checks out to bring home. I agree and accept that in the event of any accident or injury involving my child, myself, or my designated adult, I will not hold employees or volunteers of Fort Bend Hope from personal injury or other claim. *
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service