Demographic Update Form Question Title * 1. Student Name (Required.) Question Title * 2. Date of Birth (Required.) Date Date Question Title * 3. Grade (Required.) Question Title * 4. School (Required.) Question Title * 5. Graduation School Year (Required.) Question Title * 6. Home Address (Required.) Question Title * 7. Home Phone (Required.) Question Title * 8. Cell Phone (Required.) Question Title * 9. Student Email (Required.) Question Title * 10. Lives with: (Required.) Both Parents Dad Mom Guardian Other Question Title * 11. Parent/ Guardian Name (Required.) Question Title * 12. Home Phone (Required.) Question Title * 13. Cell Phone (Required.) Question Title * 14. Employer (Required.) Question Title * 15. Email (Required.) Question Title * 16. Does your student have health care coverage? (Required.) Yes No Question Title * 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 Done