GEAR UP Key-in Form Student Name: First Middle Last Student Date of Birth: MM slash DD slash YYYY GenderFemaleMalePrefer not to sayHome PhoneAddress of student: Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Which category best describes the student’s race? American Indian or Alaska Native Asian Black or African American Hispanic White Native Hawaiian or other Pacific Islander Multi-racial Prefer not to say Current Grade:Pre-KKindergarten1st2nd3rd4th5th6th7th8th9th10th11th12thStudent ID number if known: Name of parent or legal guardian: First Last Relationship to student: Mother Father Legal Guardian Is student's address the same as your own? Yes No Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Cell Phone Number:Other Phone:Email: Place of Employment: Would you like to list an additional parent or legal guardian? Yes No Name of parent or legal guardian: First Last Relationship to student: Mother Father Legal Guardian Day Phone Number:Email: Place of Employment: Emergancy Contact: First Last Phone Number:Relationship to student: What language is spoken at home? Do you need an interpreter for school system meetings involving your child’s education? Yes No Which language: Will your student need bus transportation? AM/PM (round-trip) AM only (morning rider) PM only (afternoon rider) Does not need transportation services Photo/Video Release: I deny permission to use my child’s image for display, publication or release to external organizations. I grant permission for use of my child’s image in print, video and/or digital media. I understand that my child’s image may be used or released by the the program without additional notification and that my child’s name may appear along with his or her photograph. Name Release: I grant permission for my child to be identified by name on the school or district’s Internet websites. I deny permission for my child to be identified by name on the school or district’s Internet websites. Is an immediate family member of your child connected to the U.S. Military, including Active Duty, National Guard or Reserves, Retired Military, Disabled Veteran or a Federal Civil Service Employee? Yes No Branch (required): Air Force Army Coast Guard Marine Corps Navy Status: Active Duty National Guard Reserves Retired Military Disabled Veteran Federal Civil Service Relationship to Student: Does the student have any medical conditions that school officials should know about? Yes No Including medical, diet, vision, ect. Medications prescribed for student: Student’s allergies, type, and response required: Special diet instructions:
