Bella Ease mPower Intake Form

Bella Ease mPower Intake Form
Student Information
Student Name*

First NameLast Name
Student Birthday*

MonthDayYear
Date
Student School ID Number*
If not known, please type "0"
Student Grade for the 2025/2026 School Year*
Student Grade for the 2025/2026 School Year*

6th grade7th grade8th grade9th grade10th grade11th grade12th grade
If your child is in 3rd-5th grade during the 2025/2026 school year, fill out the application at the link below:

Teen REACH/CARES Application

Bella Ease does not have programs for students in Kindergarten- 2nd grade.
School Student is Attending*
Student Gender*
Student Race*
Hispanic/Latino Ethnicity *

YesNo

Program may include physical fitness and sports opportunities. Does your student have any special needs/restrictions that staff need to be aware of?*
Allergies that staff need to be aware of?*
Medications that staff need to be aware of?*

By signing electronically, I give my child consent to join the 21st Century program. I give Bella Ease consent to communicate with Quincy Public Schools and other grant partners about my child’s involvement in this and any other grants they are a part of. I give consent for Bella Ease to collected information about my child pertaining to the grant, including but not limited to grades, MAP scores, ACT/SAT scores, grade point average, ISS/OSS data, days absent, free/reduced lunch status, IEP status, 504 plans, and involvement with other programming. With this consent, I am allowing my child to be transported by program staff. I give consent for my child to be in photos or videos. I understand that I can revoke consent at any time by calling Bella Ease at 217-209-0632.

Clear
Should be Empty:

Student Information