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.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Student Name

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

MonthDayYear
Date
Student Sex:

Other
Race:

Other
Ethnicity:

Other
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.Format: (000) 000-0000.
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?
How many members are in your household? Including yourself.
Names of Others living in Household (Include Sex, Age, Relationship to Applicant, Elderly and/or Disabled)
Please choose income for household:
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
Date

MonthDayYear
Date
Heroes Academy Enrollment Form
Should be Empty: