Please take a few moments and answer the following questions. We ask these so that we have a better idea about the students we work with, their interests, and hobbies.

Thank you so much!

Name of Student

First Name

Last Name

Name of Parent or Legal Guardian

First Name

Last Name

Email of Parent or Legal Guardian

Phone of Parent or Legal Guardian

(###)

###

####

Age of Student

School Student Attends

Grade Level of Student

Things the Student is Interested In (This can include hobbies, after school activites, sports, music, etc.)

What does the Student want to be when he/she grows up?

Please list the Student's favorite snacks, drinks, colors and t-shirt size.

Any Additional Information You'd Like to Add

Student Intake Form