Success Coach Intake Form
Please complete a form for each child that you would like to be paired with a Success Coach at Clinton Elementary, AR Rucker Middle, and/or Lancaster High School. 
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Email *
Child's Full Name: *
Child's Date of Birth: *
Child's School and Grade: *
Parent/Guardian Name: *
Address: *
Parent/Guardian Phone Number: *
Parent/Guardian Email Address:
Please List all Siblings living in the home: (Name, School, and Grade)
I would like assistance with the following:
Current Agency Involvement:
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