EmailMe Form - L.I.F.E. Program Registration 2013

Name *

First Last

Age *

Gender

Male

Female

Ethnicity: *

E-mail *

Mobile Phone *

### - ### - ####

May we text you? *

Yes

No

School

Grade Level

Zip Code *

Parent/Guardian Name *

First Last

Parent/Guardian Phone *

### - ### - ####

Parent/Guardian E-mail

Languages Spoken at Home

Do you receive Free/Reduced lunch?

Yes

No

What does *RESPECT* mean to you? *

What are your future goals/aspirations? *

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

Have you participated in the L.I.F.E. Program before? *

Yes

No

If so, how has the L.I.F.E. Program motivated you in school and or life?

How did you find out about the L.I.F.E. Program? *

Which art form(s) are you interested in for this years L.I.F.E. program? *

What additional art form(s) would you be interested in if they were available?

Outside of school, are you involved in any other community programs this summer? *

Feel free to let us know about any other interests you have

Please share any speciific needs that you have so that we can make sure you are well supported at L.I.F.E.

Do you have any identified mental health or behavioral health needs/diagnoses? *

Do you have any allergies, medical conditions, or disabilities that we can accomodate? *