ACT Inc. Student Participation Form

Student Participation Form

In order to best serve your student(s) please complete the fields below!
Student Information
Student's Full Name*

First NameMiddle NameLast Name
Grade*
Current School*

Parent/Legal Guardian Information
Parent/Legal Guardian's Full Name*

First NameMiddle NameLast Name
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*
Email Address*
Relationship to Student*

MotherFatherGrandparentAunt/UncleOther
Are you the Legal Guardian of the Student(s)?*

YesNo
Emergency Contact(s)
#1 Emergency Contact

First NameLast Name
Relationship to Student
Phone Number
#2 Emergency Contact

First NameLast Name
Relationship to Student
Phone Number
Additional Information
In which area(s) does your student need assistance? If more than one student, please select all that apply.*

MathEnglishScienceOther
Does the student have any allergies or other medical concerns? If more than one student, please list for each student.
How did you hear about American Council of Teachers Inc.?*

Church/religious organizationInternet searchSchoolFriend/familyOther
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Student Participation Form