Registration Form

Freeprenuers, Inc.

3450 Northlake Blvd suite 270

Palm Beach Gardens, FL, 33403

Website: www.freeprenuers.org

Email: info@freeprenuers.org

Ph: 561-320-1002
Registration Form
This is an important questionnaire to provide better services for your child as well as helping us to better plan for the future needs of children and their families. We would like to start by asking you some background information about you and your family. Some of these questions might not apply to you, and we apologize for that, however it is important that we ask everyone the same things so please bear with us on this. Please try to be as truthful as possible when answering these questions, but please be assured that the answers you give will be kept confidential. Your information will not be shared or sold.
- Full Name*
  
  First NameMiddle NameLast Name
- Birth Date*
  
  MonthDayYear
- Student Number
  e.g. 11183021
- Grade Level*
  for Incoming A.Y. '12-'13
- Child's Email*
- Ethnicity of the child?
  
  BlackWhiteAsianHispanic or LatinoOther/UnknownPrefer not to answer
- Primary language of the child?
  
  EnglishSpanishCreoleOtherPrefer not to answer
- Single or 2 Parent household?
  
  Single2 ParentPrefer not to answer
- Parent's Email*
  example@example.com
- Degree Program
- Phone Number
  Format: (000) 000-0000.
- Present Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- Emergency Contact*
  
  First NameLast Name
- Relationship*
  ex. Father, Mother, etc.
- Emergency Contact
  
  First NameLast Name
- Relationship
  ex. Father, Mother, etc.
- Phone number of Person to contact in case of emergency*
  Please enter a valid phone number.Format: (000) 000-0000.
- Email of Person to Contact in case of emergency*
  example@example.com
- Name of School Name
- What is your current GPA (Grade point average)?
- What is Your child's plan after college?
- Other Extra Curricular Activities
- Extra Curricular Participation
  
  Student CouncilClass OfficerClub/OrganizationVarsity PlayerOthers (please specify below)
- Skills/Talents*
  
  ActingArts/CraftsCalculatingDancingDebatingDrawingEatingFashionPhotographyPlaying drumsPlaying guitarPlaying pianoProgrammingSingingWritingCookingSewingOthers (specify below)Coding
- Sports
  
  BadmintonBasketballBowlingChessFrisbeeScrabbleSoccerSoftballSwimmingTable TennisTrack and FieldTennisVolleyballOthers (specify below)
- Interests
- Estimate Your Family Monthly Income
  
  Less than $25,000$25,000 - $50,000$50,000 - $100,000$100,000 - $200,000$250,000 and up
- Does Your child have any Scholarships?
  
  YesNo
- Is Your child currently employed outside of the home?
  
  YesNo
- Does Your child need community service hours?
  
  YesNo
- Do you know how many community service hours your child currently has? If not, please check in with your child's Guidance Counselor so that they stay on course.
  
  YesNo
- Does Your child struggle with any of these subjects?
  
  MathEnglishScienceHistorySocial StudiesOther
- Does Your child have any school problems?
  
  With subjects?With others?Following guidance?Other
- Briefly describe the child's ways of expressing the following emotions or behaviors?
  
  AngerHappinessSadnessAnxietyDepressionOther
- Does your child need any tutoring services?
  
  YesNo
- Does your child get regular health screenings?
  
  YesNo
- Do you or does your child need Mental Health Services? Do they need to be mentally evaluated? We have resources.
- List any of your child's behaviors that you would like to see changed?
- Do you or does your child need any type of assistance, if yes please explain?
- How did you hear about Freeprenuers, Inc organization?
  
  FriendNewsletterAdvertisementSocial MediaEmailReferred
- Has Your child ever attended any of Freeprenuers events/workshops?
  
  YesNo
- Suggestions / Comments
- Please verify that you are human*
- Thank you for taking the time to complete this assessment, we will be adding you to our email distribution email lists, please be sure to check your spam folders.
- Should be Empty: