New Student Registration
If you would like to register to enroll your child in Decode Project please fill out the form below. (* Required Fields)
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Email *
Student Primary Contact Information
Name of Student *
Date of Birth *
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/
DD
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Age of Student *
Name of School *
Grade *
Type of School *
T-shirt Size *
Name of Parent/Guardian/Primary Contact *
Mailing Address *
City *
State *
Zip Code *
Home Phone
Cell Phone *
Work Phone
Best way to contact you *
How would you like to receive additional paperwork? *
What is the race/ethnicity of your student? *
Knowing the demographic makeup of our students/community can assist in grant writing, intentional outreach, representation when recruiting mentors and more.
Education Information
This information will be used to ensure that the student's needs are adequately met.
Was/is your student in special education classes? *
Has/is your student receiving classroom accommodations? *
Has your student repeated a grade? *
Has your student been tested for a learning difference? *
Emergency Contacts
Please provide two additional people, different from the parent/guardian listed above, who would automatically be the first person we contact.
First Emergency Contact
First contact's name *
Relationship *
Home Phone
Work/Cell Phone *
Second Emergency Contact
Second contact's name *
Relationship *
Home Phone
Work/Cell Phone *
Safety Information
Please list all known conditions so we can accommodate your student's needs.
Does your student have any medical conditions, allergies, or special needs the staff/mentors should know about? *
Does your student have any behavioral or emotional concerns the staff/mentor should know about? *
Is your student taking any medications to treat these conditions? *
Financial Information
Decode Project seeks to foster equity in education by making our programs affordable and accessible to all students who can benefit from our services. We are able to provide services due to grants, private donations and by families who are able to contribute toward their students mentoring. Families submitting applications for multiple students will receive a discount for each additional student.
Does your student qualify for free and reduced lunch? *
Please see the sliding scale to see where your household would qualify.
In which annual income range do you qualify?
*
Are you applying for financial aid? *
Is there anything else you would like us to know?
Media Release Agreement
Throughout our programs, there may be times when Decode Project (D.P.) staff, the media, or other organizations, with the approval of D.P., may take photographs of students, audio/videotape students, or interview students for program related stories in a way that would individually identify a specific student. Those photographs and/or videotaped images or interviews may appear in D.P. publications, video productions, on the D.P. website, on D.P. authorized social networking sites such as Facebook or Twitter, in the news media, or in other organizations’ school-related stories or articles. To authorize your child’s photograph and/or videotaped image or interview to be used for these purposes, please complete this form and return to Decode Project’s admissions personnel.
Media Release Agreement *
Required
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