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Demographic Update Form
*
1.
Student Name
(Required.)
*
2.
Date of Birth
(Required.)
Date
Date
January
February
March
April
May
June
July
August
September
October
November
December
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
Su
Sunday
Mo
Monday
Tu
Tuesday
We
Wednesday
Th
Thursday
Fr
Friday
Sa
Saturday
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
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3.
Grade
(Required.)
*
4.
School
(Required.)
*
5.
Graduation School Year
(Required.)
*
6.
Home Address
(Required.)
*
7.
Home Phone
(Required.)
*
8.
Cell Phone
(Required.)
*
9.
Student Email
(Required.)
*
10.
Lives with:
(Required.)
Both Parents
Dad
Mom
Guardian
Other
*
11.
Parent/ Guardian Name
(Required.)
*
12.
Home Phone
(Required.)
*
13.
Cell Phone
(Required.)
*
14.
Employer
(Required.)
*
15.
Email
(Required.)
*
16.
Does your student have health care coverage?
(Required.)
Yes
No
*
17.
Please bring your student's health care card to orientation for us to copy. This his for their safety on campus.
If they do not have health care we will work with you to obtain coverage if possible.
(Required.)
I will bring my student's health care card to orientation
My student does not have health care and I will work with Upward Bound to obtain coverage
Please call me as I am not sure how to handle this situation around health care