SSEP Registration Student InformationPlease provide the following information about the studentStudent Name(Required) First Last Gender(Required) Male Female Non-binary Prefer to self-describe Prefer not to answer Other Required for demographic reportingRace/Ethnicity(Required) White or Caucasian Black or African American Hispanic or Latino/a Asian or Asian American American Indian or Alaska Native Another Race Prefer not to answer Other Required for demographic reportingGrade(Required)K123456789101112Zip Code(Required)Required for tracking program service areasHas the student participated in this program in the previous year?(Required) Yes No Parent/Guardian InformationPlease provide contact information for the student's parent or guardianParent/Guardian Name(Required) First Last Email PhoneEmergency Contact InformationPlease provide emergency contact information if different from parent/guardianEmergency Contact Name First Last If same as parent/guardian, leave blankRelationship to StudentEmergency Contact PhoneMedical InformationPlease provide any relevant medical informationAllergiesPlease list any allergies the student hasMedical ConditionsPlease list any medical conditions the student hasConsentMedia Release(Required) I give permission for my child to be photographed or recorded during program activities I do not give permission for my child to be photographed or recorded during program activities Δ
