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Student Information
Student Name
*
First Name
Last Name
Nickname/Alias, if applicable
Gender
Male
Female
Date of Birth
*
-
Month
-
Day
Year
Date
Grade Entering in 2020-2021 School Year:
*
--Select grade--
Pre-Kindergarten
Kindergarten
1
2
3
4
5
6
7
8
9
10
11
12
GED/Alternative Program
College/Career
What program site will the child attend?
*
Esperanza Elementary OKCPS
Rockwood Elementary OKCP
EmpowerOKC (1841 Exchange Avenue)
St. Luke's Asbury United Methodist Church (1320 SW 38th St.)
Capitol Hill Church of Christ (2801 S. Robinson Ave.)
Oklahoma City Youth/Teen
I Don’t Know
Is this student in foster care?:
YES
NO
I DON'T KNOW
If yes, what type of placement are they in?:
Kinship, Foster home, Group home, etc.
If yes, Permanency Worker name:
If yes, Permanency Worker phone:
If yes, Permanency Worker email:
If no, has this student previously been placed in foster care?:
YES
NO
I DON'T KNOW
Parent/Caregiver Information
Parent/Caregiver First Name
Parent/Caregiver Last Name
Nickname/Alias, if applicable
Parent/Caregiver Phone 1
-
Area Code
Phone Number
Parent/Caregiver Phone 2
-
Area Code
Phone Number
Parent/Caregiver Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Caregiver Email
*
Relationship to child
parent
guardian
foster parent
other
Other: Please describe
Verification
*
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