L.I.F.E. Summer 2011 (1316 Martin Luther King Jr St, Tacoma WA 98405) http://www.fab-5.org

Student Name *

Age *

E-Mail *

Phone *

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May We Text You?

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School: *

Grade: *

Parent Information:

Parent Name *

Parent Phone *

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Parent E-Mail

Student Info Cont.

Please select your ethnic background: *

African-American/Black   Asian/Pacific Islander   Caucasion/White   Latino/Hspanic   Native American

Do you recieve free or reduced lunch? *

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Are you a Special Needs Youth? *

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If so, how can we better assist your needs?

Do you have any medical conditions we need to be aware of? *

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What does respect mean to you? *

What do you hope to get out of being involved with Fab-5 and the L.I.F.E. program? *

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