Heroes Academy Enrollment Form

Parent/Guardian Name*

First NameLast Name
Parent/Guardian Email*
example@example.com
Parent/ Guardian Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Work Phone Number
Please enter a valid phone number.
Student Name*

First NameLast Name
Student Email
example@example.com
School Attending*
Student Grade*
Student Age*
Student Birthday*

MonthDayYear
Date
Student Sex:*

MaleFemalePrefer Not To SayOther
Race:*

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteAmerican Indian or Alaska Native and WhiteAsian and WhiteBlack or African American and WhiteAmerican Indian or Alaska Native and Black or African AmericanOther
Ethnicity:*

Hispanic/LatinoNot Hispanic/ LatinoOther
In case of emergency, contact name:*

First NameLast Name
In case of emergency, contact relationship*

Mother, father, grandparent, etc.
In case of emergency, contact phone number*
Please enter a valid phone number.
Please tell us about your child; his victories, his challenges, his academics and what you would like us to help him with*
Please list any food allergies, medical information (including regular taken or medicines they may have with them), personal information that staff/mentors may need to know. Note: Staff/mentors will not be responsible for dispensing medication.*
Female Head of Household?*

YesNo
How many members are in your household? Including yourself.*

12345678
Names of Others living in Household (Include Sex, Age, Relationship to Applicant, Elderly and/or Disabled)*
Please choose income for household:*

Under $10,000$10,000-14,999$15,000-24,999$25,000-34,999$35,000-49,999$50,000-74,999$75,000+Not Known
I certify that to the best of my knowledge, all statements made on this form are true and correct and that I am not receiving benefit from any other program funded by the City of Wichita. I understand that it may be a federal crime to knowingly make any false statements concerning any of the above facts as applicable under the provisions of the United States Criminal Code.
Signature*

Clear
Date*

MonthDayYear
Date
Heroes Academy Enrollment Form
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