United We Can Registration Form

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Student's last name *

Student's first name *

Date of birth *

YYYY

Gender *

Race & Ethnicity *

Parent / Guardian name (full name) *

Address (please provide a complete address) *

Primary phone number *

Secondary phone number

Preferred language *

Preferred method of communication *

What grade level is the student currently in? *

What school does the student currently attend? *

What middle school will the student be attending? *

Is the student on an IEP (Individualized Educational Plan)? *

Is the student in ELL classes (English Language Learner)?

Will the student be attending TPS summer school? *

Are you interested in enrolling your student into United We Can's 2019 Summer Academy? *

Has the student had conduct issues (detention, suspension etc.)? *

Never

Always

Is the student enrolled in other programs (Day Spring, Camp Fire, etc)? *

Does your child have a sickness or special condition that we should be aware of (for example, allergies, diet restrictions, seizures)?

Is there an existing family situation that we should be aware of?

How did you hear about United We Can? Please provide as much detail as possible. *

Who were you referred by?

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