Name * First Name Last Name Birth Date * MM DD YYYY Age * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone * (###) ### #### Name of Parent/Guardian * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Emergency Contact First Name Last Name Phone (###) ### #### Current School * School Address Address 1 Address 2 City State/Province Zip/Postal Code Country 2022/2023 Grade Shirt Size * X Small Small Medium Large X Large Gender * Male Female Ethnic Background Native American Indian/Alaskan Black (Other than Hispanic) White (Other than Hispanic) Asian/Pacific Islander Hispanic • List the school activities, clubs, organizations or sports teams in which you participated during this school year. • How often do you read published print, ie; magazines, books, novels or newspapers? Regularly Sometimes Rarely Never How did you hear about the program? Thank you!
