SuperSeeds - Transformation Camp Registration

SuperSeeds - Transformation Camp Registration
For youth ages 13-17 Thank you for your interest in registering your youth for the 2-Day Transformation Camp. Please complete the form below. Once we receive your registration, we will confirm your child's spot.
First Name
Last Name
Middle Name
Date of Birth

MonthDayYear
Date
Gender
Race
Address
City
State
Zip
Home Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Email
example@example.com
ParentGuardian First Name
ParentGuardian Last Name
Address
Phone
Format: (000) 000-0000.
Email
example@example.com
Employment Status
Annual Household Income
Total Dependents in Household
Marital Status
School Name
Grade Level
Current GPA
Has your child repeated a grade? Yes / No Average Academic Grades
School Attendance per Week
Lunch Status
Behavioral & Court Information
Average Behavioral Referrals
Has your child been suspended or expelled? Yes / No

Alternative School Placement? Yes / No Juvenile Court Recommended? Yes / No

Was your child convicted of a crime? Yes / No

Has your child been tested/treated for: Autism / ADHD / Depression / Other:
Other
Interested in other SuperSeeds Programs? Yes / No If Yes, how often? Weekly / Monthly / Annually
How can we better support you
Anything else we should know
Consent I certify that the above information is accurate to the best of my knowledge. I give permission for my child to participate in the SuperSeeds Transformation Camp.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty: