PWC Student Interest Form
First Name
Last Name
Nickname (if applicable)
Current Grade
Age
DOB
MM
/
DD
/
YYYY
PUSD Student ID #
Home Address (# Street, city)
Home phone
Parent/Guardian Name
Parent/Guardian Cell Phone Number
Student Cell Phone Number
Ethnicity
Home Language
Does the student have any allergies? If so, please describe:
Does the student have any major health issues? If so, please describe:
Program of interest:
Clear selection
EMERGENCY CONTACT INFORMATION
First and Last Name
Relationship to Student
Phone number
Address
Thank you for your interest! We will contact you soon!
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