Student's Full Name *

Date of Birth *

Email (Student)

Email (Parent)

Street Address *

Town *

State, Zip Code *

Cell Phone Number (Parent) *

Home Phone Number (Parent)

Cell Phone number (Student)

Name of the School Student Attends *

GRADE ENTERING IN SEPTEMBER *

Do you receive free or reduced price school lunch? *

Services Interested In (September -June)

Services Interested In (September -June)

Where did you hear about this program? *

By submitting this form I confirm that I am at least 18 years of age, and provide my written consent for Million Reasons to contact me/my child using email or telephone and provide academic enrichment services to my child/children. I understand that only those receiving free or reduce price school lunch is eligible to receive the free services of Million Reasons and that I have to send the appropriate documents to Million Reasons to be accepted to the free programs. *

Name of Parent/Guardian: *

Parent's Signature *

Date *