two:fiftytwo Student Application

Student Information

Student Name

First Name

Last Name

Birthday

YYYY

Age

Gender

Male

Female

Grade

School

Student ID Number

(For KIPP students can be found on Report Card)

Last 4 of Social Security Number

Teacher Name(s)

If multiple teachers, please separate with comma

Student's Strongest Subject

Student's Weakest Subject

Does the student have special learning plans?

i.e. an IEP or 504

Yes

Any health or behavior concerns?

i.e. allergies, ADHD, chronic headaches, asthma, disabilities, etc.

Parent/Guardian Information

Parent / Guardian Name

First Name

Last Name

Relationship to Student

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Phone

(###)

###

####

Secondary Phone

(###)

###

####

Emergency Contacts

Please give emergency contacts in case we cannot get a hold of you during the program.

Emergency Contact 1

First Name

Last Name

Phone

(###)

###

####

Relationship to Student

Emergency Contact 2

First Name

Last Name

Phone

(###)

###

####

Relationship to Student

Others authorized to pick up student

List all names of individuals allowed to pick up this students other than names listed above (Photo ID confirmation may be requested)