Athletes for Kids Child Information Child First Name Child Last Name Home Phone Date of Birth RegistrationPlease select... New Registration Rematch GenderPlease select... Male Female Other Current School Feeder High School Please select... Bellevue High School, Bellevue, WA Eastside Catholic High School, Sammamish WA Eastlake High School, Sammamish WA Issaquah High School, Issaquah, WA Juanita High School, Kirkland, WA Lake Washington High School, Kirkland, WA Liberty High School, Renton, WA Mercer Island High School, Mercer Island, WA Newport High School, Bellevue, WA Redmond High Schools, Redmond, WA Skyline High School, Sammamish WA(If your child's school is not on this list, please e-mail us at firstname.lastname@example.org) Current Grade Please select... First Second Third Fourth Fifth Sixth Seventh Eight Ninth(If outside this age range please e-mail us at email@example.com) Medical Information Child's disability,special need, IEP, other (please elaborate) Hospital/Clinic Preference Any medical conditions, restrictions, allergies Say none if not relevant Specific instructions if a medical emergency occurs Additional Information Why are you interested in a mentor for your child? How did you hear about our program?* Child's Home Address Street City StateWA Postal Code Parent/Guardian #1 (Required) First Name Last Name Parent Email Cell Phone Company Occupation Home Address Same as above Different address Parent / Guardian # 1Address Street City StateWA Postal Code Parent/Guardian # 2 (Required) First Name Last Name Email Cell Phone Company Occupation Home Address Same as above Different address Parent / Guardian # 2 Address Street City StateWA Postal Code Goals What areas of improvement would you like to see in your child through a mentorship relationship? (check all that apply) Confidence Classroom behavior Self esteem Friendship Social skills Other Happiness Demographic Information Providing this information helps Athletes For Kids receive critical funding. As with all of the information we collect, your demographic information will be kept confidential and never shared.k here to enter text Total household incomePlease select... Under $20,000 $20,000-$30,000 $30,000-$40,000 $40,000-$50,000 $50,000-$75,000 $75,000-$100,000 $100,000-$150,000 $150,000 or more Prefer not to answer Single parent household Yes No Number of persons in householdPlease select... 2 3 4 5 6 7 8 Is either parent a US Veteran? Yes No Race of child (select all that apply) White/Caucasian Alaska Native African American Latino American/Hispanic Native Hawaiian/Pacific Islander American Indian Asian Other Prefer not to answer What is the primary language spoken at home? Is your child currently receiving DDA benefits? Please select... No Yes Applied for benefits in the past Prefer not to answerFor DDA services and information please visit https://www.dshs.wa.gov/dda Emergency Contact # 1 / Nanny / Caregiver Information (Required) First Name Last Name Cell Phone Emergency Contact # 2 (Required) First Name Last Name Cell Phone reCAPTCHA helps prevent automated form spam. The submit button will be disabled until you complete the CAPTCHA. Need assistance with this form?