2022-2023 P.A.R.K. Nomination Form

Please take a moment to consider the student you have selected for membership in our program. It is very important that you give an accurate assessment of the student’s skills and abilities. It will help in determining the student’s chances for success in P.A.R.K.

Early Selection Deadline is Friday, December 2, 2022.

Final Nomination Deadline is Friday, March 10, 2023.

Name of Student*

Date of Birth *

Example: 05/16/03

Gender:*

MaleFemale

Race

Ethnicity

Student's T Shirt Size

Grade*

7th8th

Current School Learning Choice*

On-Site SchoolingVirtual Schooling

Please select your child's current middle school from our list of partner schools below:*

Current GPA (based on most recent report card)

(Please attach a copy of the most recent report card to this form.)

Upload Report Card Here

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Parent/Guardian(s) Name:*

First NameLast Name

Relationship to student*

Contact Phone Number*

Enter a valid phone number with area code.

Would you like to receive text communication?

YesNo

Email Address

example@example.com

Would you like to receive email communication?

YesNo

Mailing Address*

Street Address

Street Address Line 2/Apartment Number

CityState / Province

Postal / Zip Code

How did you hear P.A.R.K.'s recruitment?*

If you selected "Other" for the previous question, please explain how you first heard about P.A.R.K.

Nominating Counselor/Teacher/Staff (If Applicable)

First NameLast Name

Please state why you feel this student needs P.A.R.K.*

Guardian's Signature

To access student's report cards Clear

Date

Please Note: This application is not complete and cannot be reviewed for selection until a first or second nine weeks report card is submitted to P.A.R.K.

For further questions or comments, you may contact P.A.R.K. at:

● 6915 Geyer Springs Rd, Little Rock, AR 72209

● Email: park@positivekids.org

● Work: 501-562-5223 ● FAX: 501-562-5877

● Check out our website: www.positivekids.org

2022-2023 NOMINATION FORM