Please make best effort to complete this form in one sitting. Incomplete entries will not be submitted

*1.School aged children or Student’s Name (First and Last Name):(Required.)

Student 1:

Student 2:

Student 3:

Student 4:

Student 5:

Student 6:

Student 7:

Student 8:

*2.Student Date of Birth (enter as MM/DD/YYYY):(Required.)

Student 1:

Student 2:

Student 3:

Student 4:

Student 5:

Student 6:

Student 7:

Student 8:

*3.School (last attended or are currently enrolled)(Required.)

1:

2:

3:

4:

5:

6:

7:

8:

*4.Grade:(Required.)

Student 1:

Student 2:

Student 3:

Student 4:

Student 5:

Student 6:

Student 7:

Student 8:

*5.Parent Name:(Required.)

*6.Street Address (Including City, State, And Zipcode)(Required.)

*7.List any schools the student(s) attended immediately before the family became displaced?(Required.)

*8.Guardian/Caregiver (if living with someone other than a parent):(Required.)

*9.Email:(Required.)

*10.Best contact phone number:(Required.)

*11.Emergency phone contact: (Someone who will always know how to locate you) Please also state the name of the contact.(Required.)

*12.Do you wish for your students to remain at their current school (school of origin)?(Required.)

Yes

No

*13.Do you wish for your students to receive transportation?(Required.)

Yes

No

*14.Please indicate if your child is, or plans to be a student athlete during this current school year.(Required.)

Yes

No

*15.If yes, which Sport does the student intend to play?(Required.)

*16.Presently, do you and/or your family lack a fixed, regular, and adequate nighttime residence in any of the following situations? Check one box.(Required.)

Staying in a shelter

Staying with someone due to an eviction/foreclosure, domestic violence or another situation rendering the family homeless

Living in a car, park, campground, public space, abandoned building, or substandard housing

Temporarily living in a motel or hotel due to loss of housing or a similar reason

Other

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