Heroes Academy Enrollment Form

Heroes Academy Enrollment Form
Parent Name*

First Name Last Name
Parent Email*
example@example.com
Student Name*

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

MonthDay Year
Date
Home Phone Number*
Please enter a valid phone number.
Work Phone Number*
Please enter a valid phone number.
Alternate Phone Number
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
In case of emergency, contact name:*

First Name Last Name
In case of emergency, contact relationship*

First Name Last Name
In case of emergency, contact phone number*
Please enter a valid phone number.
In case of emergency, second contact name

First Name Last Name
In case of emergency, second contact relationship

First Name Last Name
In case of emergency, second 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.*
Sex:*

MaleFemalePrefer Not To SayOther
Female Head of Household?*

YesNo
Names of Others living in Household (Include Sex, Age, Relationship to Applicant, Elderly and/or Disabled)*
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 American Indian or Alaska NativeHispanic AsianHispanic Black or African AmericanHispanic Hawaiian or Other Pacific IslanderHispanic WhiteHispanic American Indian or Alaska Native and WhiteHispanic Asian and WhiteHispanic Black or African American and WhiteHispanic American Indian or Alaska Native and Black or African AmericanHispanic/LatinoRussianOther
How many members are in your household? Including yourself.*

12345678
Please choose income for 1 member:

$0 - $15,300$15,300 - $25,550$25,550 - $40,850Over $40,850
Please choose income for 2 members:

$0 - $17,500$17,500 - $29,200$29,200 - $46,650Over $46,650
Please choose income for 3 members:

$0 - $19,700$19,700 - $32,850$32,850 - $52,500Over $52,500
Please choose income for 4 members:

$0 - $21,850$21,850 - $36,450$36,450 - $58,300Over $58,300
Please choose income for 5 members:

$0 - $23,600$23,600 - $39,400$39,400 - $63,000Over $63,300
Please choose income for 6 members:

$0 - $25,350$25,350 - $42,300$42,300 - $67,650Over $67,650
Please choose income for 7 members:

$0 - $27,100$27,100 - $45,200$45,200 - $72,300Over $72,300
Please choose income for 8 members:

$0 - $28,150$28,150 - $48,150$48,150 - $77,000Type option 4
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*

MonthDay Year
Date
Should be Empty:

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