Parent / Guardian Relationship to Student
*
Parent / Guardian Name
*
First Name
Last Name
Parent / Guardian Email
*
Parent / Guardian Cell Phone
*
(###)
###
####
Student Name
*
First Name
Last Name
Student Date of Birth
*
MM
DD
YYYY
Gender
*
Male
Female
Race
*
Asian
American Indian / Alaska Native
Black / African American
Native Hawaiian / Other Pacific Islander
White
Multiracial
Other
Ethnicity
*
Hispanic
Non-Hispanic
Student Cell Phone
(###)
###
####
Does the student have siblings in the mentoring program?
*
Health Insurance Provider
*
HCI - Blue Cross Community Health Plans
HCI - County Care Health Plan
HCI - IlliniCare Health
HCI - Meridian Health Plan
HCI - Molina
HCI - Next Level Health Partners
Medicaid
Medicare
No Insurance
Other
Private
If Other or Private Insurance, Please Specify
Student's Primary Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Household Income Range
*
Less Than $50,000
$50,000 - $75,000
$75,001 - $100,000
Greater Than $100,000
Total Number of Children in the Household
*
Household Type
*
Single Parent Household
Both Parents
Legal Guardianship
Multiple Families
School
*
Brooks Middle School
Julian Middle School
Grade
*
6th
7th
8th
Student ID #
*
Academic Support Needed
*
If Other, Please Specify
Student Behavior Support Services
*
If Other, Please Specify
Does the student participate in Special Education or have an IEP?
*
Does the student receive free or reduced lunch?
*
Does the student have permission to walk home or take public transportation after the mentoring program?
*
Authorized pickup person(s):
*
Please include name, relationship, and phone number.
Please note any allergies or dietary restrictions:
Anything else you would like to share about your student and how we can best support them?
