School Registration
Keith Williams Foundation Success Center
Building Lives Restoring Hope
Student Information
Please fill out application completely
Name
First Name
Last Name
SSN
Birth Date
-
Month
-
Day
Year
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Gender
Please Select
Male
Female
Ethnicity
Please Select
African American
Hispanic/Latino
Asian
Caucasian
Native American/Alaskan
Hawaiian/Pacific Islander
Middle Eastern
Prefer not to answer
Other
Email Address
Phone Number
Please enter a valid phone number.
Present Grade
Semester
Have you previously applied to or attended this school?
Yes
No
If yes, what year?
Current Residence Information
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
-
Area Code
Phone Number
Primary Residence Information (if different from above)
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Residence Information (if different from above)
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
Emergency Contact 1
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Emergency Contact 2
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Physician and Medical Information
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Preferred Hospital
Insurance/Health Coverage (Company)
Please list any of the following: Current medications, Medication allergies, Food allergies, Chronic health concerns.
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Next
Present or Previous School of Student
School Name
City
State
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Date Started
-
Month
-
Day
Year
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Date Ended
-
Month
-
Day
Year
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Notes
Please inform the office of any other vital information you think they may need to know in the event of an emergency. Thank you.
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