Student Registration Form

Student Registration Form

Enter requested information in each space provided
Contact Information
Student First name:
Middle name:
Last name:
Student is:
Birthdate:
(MM/DD/YYYY)
Ethnicity:

Other
Student Ethnicity
Student email address:
If available
Student cell number:
If available
SHINES number:
(add if student is in foster care)
Case Manager Name (if student in foster care)

First NameLast Name
Case Manager Phone Number

Area CodePhone Number
Student is enrolled in:
Name of current school:
Enter the full name of the school student is currently attending
Current grade level
Expected graduation date:
(enter month/year student is anticipating graduation)
Guardian Information
Legal guardian Name:
(If student is their own legal guardian, please complete this section with student info)
Guardian email address:
Guardian emergency number:
Street address:
Enter Guardian's street address. No P.O. boxes.
City:
State:
Zip:
County:
Guardian: I understand there are forms that are required to be filled out, and I agree to be the primary point person to help make sure these forms are completed. I understand that without the forms being completed, the youth may not be able to continue participating in the class.
Guardian Name
(enter guardian's name below in agreement)
Name of person completing this form:
Phone number of person completing this form:
Email address of person completing this form:
Questions? Email: info@theODBI.org
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Submission constitutes agreement to the terms listed above.
Name

First NameLast Name
Should be Empty:

Student Registration Form

Contact Information

Guardian Information