GEAR UP Key-in Form Student Name: First Middle Last Student Date of Birth: Date Format: 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 NativeAsianBlack or African AmericanHispanicWhiteNative Hawaiian or other Pacific IslanderMulti-racialPrefer not to sayCurrent Grade:Pre-KKindergarten1st2nd3rd4th5th6th7th8th9th10th11th12thStudent ID number if known:Name of parent or legal guardian: First Last Relationship to student:MotherFatherLegal GuardianIs student's address the same as your own?YesNoAddress 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?YesNoName of parent or legal guardian: First Last Relationship to student:MotherFatherLegal GuardianDay 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?YesNoWhich language:Will your student need bus transportation?AM/PM (round-trip)AM only (morning rider)PM only (afternoon rider)Does not need transportation servicesPhoto/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?YesNoBranch (required):Air ForceArmyCoast GuardMarine CorpsNavyStatus:Active DutyNational GuardReservesRetired MilitaryDisabled VeteranFederal Civil ServiceRelationship to Student:Does the student have any medical conditions that school officials should know about?YesNoIncluding medical, diet, vision, ect. Medications prescribed for student:Student’s allergies, type, and response required:Special diet instructions:
