Shiloh HS After School Program
Registration Form
Name
*
First Name
Last Name
Age
*
Grade Level
*
Please Select
6th
7th
8th
9th
10th
11th
12th
Not Currently in School
DOB
*
-
Month
-
Day
Year
Date
Parent / Guardian Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
I would like to receive updates via text message:
*
Yes
No
Sex: What sex were you assigned at birth, on your original birth certificate?
*
Male
Female
Sex: How do you describe yourself? (Gender/Sex)
*
Male
Female
Do Not Wish to Identify
Hispanic / Latino?
*
Yes
No
Race / Ethnicity
*
White
Black or African-American
Asian
American Indian or Alaska Native
Native Hawaiian/Other Pacific Islander
More than One Race
Unknown/Do Not Wish to Identify
Other
When at home with family what language or languages are usually spoken?
*
English
Spanish
Chinese Languages such as Mandarin or Cantonese
Other
County (Gwinnett, Dekalb, etc.)
*
I acknowledge that if I participate in a minimum of 10 out of 13 lessons that I will receive a gift card incentive with a value of $25: (may not be redeemed for cash, for the purchase of tobacco, alcohol or firearms)
*
Yes
Signature
*
Submit
Should be Empty: