D.R.E.A.M. Academy Student Registration Form

D.R.E.A.M. Academy Student Registration
Student's Name*

First NameLast Name
Gender*
School*
Grade*
Age*
Birthday*

MonthDayYear
Date
Student's Academic Strength(s)*
Student's Academic Challenge(s)*
Race*

African American/ BlackHispanicCaucasian/ WhiteAsianAmerican Indian or Alaskan NativeOther

Student's Classroom Confidence?*

	1	2	3	4	5

1 is Very little, 5 is Excellent

Please give a brief description of the student's personality (ex. Shy, Outgoing, Kind etc.)*
Medical Conditions
Allergies
Teacher*
Teacher's Email*
example@example.com
Parent's Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Parent's Email*
example@example.com
Preferred Communication*
Primary language spoken in student's home?*

EnglishSpanishASLOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Household Income (for office use only, does not determine eligibility)*
Dual or Single Parent Household (for office use only, does not determine eligibility)*
Do you give permission to C.A.R.E. University (D.R.E.A.M.'s parent organization) and/ or Tolson staff & volunteers to contact your student's school teacher, counselor, administration to discuss academic and social information
Do you give C.A.R.E./ D.R.E.A.M. Academy/ Tolson Center for Excellence and or other community partners to use photos of your child in marketing materials and or social media?
Privacy Statement: The personal information above is collected in order to create a personalized plan for your student. The information may be shared with program and organization partners, only when necessary.

By signing this, I acknowledge that the information I've given is accurate and is able to be shared on a as needed basis.
Parent / Guardian Signature*

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