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Student's Info

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* 1. Today's Date

Date

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* 2. Student Name

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* 3. Student DOB

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* 4. Student's Cellphone

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* 5. Student's Email

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* 6. Student's High School

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* 7. Current Physical Address

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* 8. Student's Grade Level

A First Generation Student is defined by if the student's parent/guardian completed a four-year degree or bachelors degree.

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* 9. Is the student a First Generation Student?

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* 10. Student's Tribal Affiliation

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* 11. Does your student live in a single or two parent household?

Parent/Guardian Contact Info

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* 12. Parent/ Guardian Name

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* 13. Home Phone

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* 14. Cell Phone

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* 15. Mailing Address

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* 16. Parent/Guardian's Email

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* 17. As a parent/guardian, are you interested in serving as a Parent Liaison?

Emergency Contacts

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* 18. Emergency Contact 1

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* 19. Emergency Contact 2

Teacher Recommendation
If one of your child's teachers thinks they would benefit from any of the EPSS services, please list the instructor's name and contact. This will be considered in application review process.

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* 20. Teacher's Name

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* 21. Teacher's Contact

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* 22. Annual Income Range

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* 23. The importance of my child's school attendance.

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* 24. The importance of my child's school grades.

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* 25. What services are you requesting for your children?

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* 26. Why are you requesting these services?

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* 27. What is your child's academic goals? (Please have student list a goal)

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* 28. How close is your child to achieving their academic goal?

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* 29. As a parent/guardian, what are your academic goals for your child?

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* 30. How close is your child to achieving your academic goals for them?

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