Student Information

Student First Name

Student Middle Name

Student Last Name

Birth Date

School

Student ID Number

Student Grade

Home Address

City

State

Zip Code

Student Lives With

Race

Ethnicity

Not Applicable

Hispanic

Haitian

Other

Primary Language Spoken

T-Shirt Size

Other Student Information

Tutoring Days

Piano Lab Registration

Yes

No

Pick-Up Time

:

Transportation Need

Yes

No

Academic and Music Needs

Allergies/Medical Condition

Yes

No

Allergies/Medical Condition Details

Regular Medication

Yes

No

Current Medication List

Special Needs/Disability

Yes

No

Help Child Receives

Ways Student Communicates

Speaks and is easily understood

Speaks but is difficult to understand

Uses communication devices like pictures or a board

Uses gestures or expressions like pointing, pulling, smiling, frowning or blinking

Uses sign language

Uses sounds that are not words like laughing, crying or grunting

Free/Reduced Lunch

Yes

No

Parent/Guardian Information

Parent/Guardian First Name

Parent/Guardian Last Name

Relationship to Student

Country/Region

Address

City

Zip / Postal code

Email

Phone Number

Highest Level of Education

Household Information

Household Size

Annual Household Income

Languages Spoken at Home

English

Spanish

Creole

Emergency Contacts

Emergency Contact 1

Emergency Contact 1 First Name

Emergency Contact 1 Last Name Name

Relationship to Student

Phone Number - Cell

Phone Number - Home

Phone Number - Work

Emergency Contact 2

Emergency Contact 2 First Name

Emergency Contact 2 Last Name

Relationship to Student

Phone Number - Cell

Phone Number - Home

ZOE LIVE CREATIVE ARTS ACADEMY

Creative Lab After-School Program

Registration Form

Student Information

Parent/Guardian Information

Household Information

Emergency Contacts