Rise Up! Student Application Form 2017-2018
Students First Name:
Your answer
Middle Name:
Your answer
Last Name:
Your answer
Complete Address:
Your answer
Date of Birth:
MM
/
DD
/
YYYY
School:
Current Grade Level:
Your answer
Guardian's Full Name:
Your answer
Home Phone Number:
Your answer
Work Phone Number:
Your answer
Email:
Your answer
Number of People Living in Home:
Your answer
Household Income:
Medical Conditions / Allergies:
Your answer
Behavioral Issues:
Your answer
Which program is your child attending?
Required
Would you like your child to have a mentor?
Is there a parent in jail or prison?
..If yes, whom?
Your answer
Did Mom graduate college?
Did Dad graduate college?
Please indicate below person(s) who are allowed to pick up your child, separate answers with commas:
Your answer
I/we by law may do so; authorize the administration medical treatment to he/she who is subject of this form. I/we understand all reasonable safety precautions will be taken at all times. I understand that in the event medical intervention is needed every attempt will be made to contact the above persons immediately. I authorize Rise Up to give my child sunscreen if needed. I/we recognize that one of the primary purposes of Rise Up is to maintain and improve school performance. This release gives permission for the JC School System to discuss the behavior and academic performance of my child. I/we do hereby further release and guard Rise Up and or any other facility and their staff and or officers from any cause of action resulting from circumstances which may arise from any activity and or field trip and do agree to hold Rise Up and their staff and officers and agents blameless in the event of an emergency action on behalf of my child named above. I/we give permission for Rise Up to publish my child’s picture. I/we give permission for the school to release my child to Rise Up staff for transportation to the program. Rise Up agrees, parents, and assures that no persons shall that no person shall be excluded from participation in, be denied benefits of, or be otherwise subjected to discrimination on the grounds of disability, age, race, color, religion, sex, national origin or any other classification protected by Federal, an Tennessee State commission or statutory law.
Guardian's Digital Signature:
Your answer
Date:
MM
/
DD
/
YYYY
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