Agents of Change interest form

school-year program

for students ages 11-15
Parent/guardian information
Your full name
Primary phone number
Format: (000) 000-0000.
Email
Household Information

We appreciate you sharing some demographic information about your family. Knowing these details about who participates in our programs helps us secure funding to continue offering them!
Street address
Zip code
Total number of people in your household

Other
Household of 2 income level
Household of 3 income level
Household of 4 income level
Household of 5 income level
Household of 6 income level
Household of 7 income level
Household of 8 income level
If there are 9 or more people in your household, please list the household's annual income
Student information
Student's full name

first namelast name
Student's date of birth

MonthDayYear
Eligible?
Peaslee's Agents of Change program is for students who are between 11 and 15 years old.

According to the date of birth you have entered, this student is not eligible for Agents of Change.

Please check the date of birth to be sure it is entered correctly. If it is correct but you think the student should be eligible, please call Peaslee at 513-621-5514.

school-year program