AmazinnMe
2025-2026 ENROLLMENT FORM
Student Information
Name
First Name
Last Name
Student Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Current Age
Please Select
8
9
10
11
12
13
14
15
16
17
14
15
16
17
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Ethnicity
Black/African American
Caucasian/White
Asian
American Indian/Alaskan
Hispanic
Other
School Name
Current Grade
Parent/Guardian 1
Contact Information
Name
First Name
Last Name
Relationship
Email
example@example.com
Street Address (if different from above)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Number
Format: (000) 000-0000.
Parent/Guardian 2
Contact Information
Name
First Name
Last Name
Relationship
Email
example@example.com
Street Address (if different from above)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contacts
Please provide contact information for two individuals who can be reached in case of an emergency if you are unavailable.
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Additional Information
The following information is optional but will help us provide the best opportunities for your child.
Number of siblings enrolled in the program?
Please Select
0
1
2
3
4
5
Is your child Limited English Speaking/LEP?
YES
NO
Other
Does your child have an IEP? If yes, please share with appropriate program staff.
YES
NO
Has your child been identified as gifted/talented? If yes, please share with appropriate program staff.
YES
NO
Other
AmazinnMe is partnering with Heart to Heart Health and Wellness (H2H) to offer Therapeutic Behavioral Support, Mental Health Therapy, Community Psychiatric Support Treatment, and Diagnostic Assessments. These services address mental, social, and behavioral health needs. If you or your child could benefit from these services or would like more information, please indicate your interest below:
Interested
Not Interested
I understand that the AmazinnMe program will run throughout the academic year 2025-2026 and during the summer. I grant permission for my child to attend and participate in the program on the scheduled dates and times, which are to be announced. I also acknowledge that regular attendance in the AmazinnMe program will contribute to enhancing my child’s abilities.
MEDIA RELEASE
I grant permission to AmazinnMe to use my image (photographs and/or video) in media publications, including videos, email blasts, recruiting brochures, newsletters, magazines, general publications, the website, and/or affiliates.
YES
NO
Parent Signature
Print Name
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Office Use Only
Date of Enrollment
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date of 30 days of attendance
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date of 60 days of attendance
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date of Withdrawal
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Assigned Tutor(s) Authorization
Updated 1/16/2026
AmazinnMe Nonprofit Organization
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