Date
*
-
Month
-
Day
Year
Date
PARENT/GUARDIAN
*
Parent/Guardian's Email
example@example.com
Child's Name
*
CHILD'S FIRST NAME
CHILD'S LAST NAME
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
HOME PHONE
-
Area Code
Phone Number
CELL PHONE
*
-
Area Code
Phone Number
CHILD'S GRADE
*
CHILD'S SEX
*
CHILD'S RACE
*
Reason For Referral - Check all that apply
Behavior
Education
Mentioring
Social Skills
Employment
Other
Child's Shirt Size
*
Child's Pants Size
*
Child's Dress Size
*
Child's Shoe Size
*
I, the parent or guardian of the above listed child, agree to my child participating in the Role Model R.E.A.D. Program. Parent/Guardian Signature
*
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