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SSEP Registration

Student Information

Please provide the following information about the student
Student Name(Required)
Gender(Required)

Required for demographic reporting
Race/Ethnicity(Required)

Required for demographic reporting
Required for tracking program service areas
Has the student participated in this program in the previous year?(Required)

Parent/Guardian Information

Please provide contact information for the student’s parent or guardian
Parent/Guardian Name(Required)

Emergency Contact Information

Please provide emergency contact information if different from parent/guardian
Emergency Contact Name
If same as parent/guardian, leave blank

Medical Information

Please provide any relevant medical information
Please list any allergies the student has
Please list any medical conditions the student has

Consent

Media Release(Required)

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