Feed Your Brain, Alimenta tu Cerebro Registration Forms_English

School:*

Year*

Please enter a number from 2020 to 2030.

Academic term*

Mr./Mrs. Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Alt. Phone Number

Email

Ethnicity*

Relationship	Ethnicity

Father____________ Mother:_______________ Children:_________________________________

Employer: Father

Employer: Mother

Number of People in Family:*

Please enter a number from 1 to 50.

Annual Income:*

Your Child’s Name*

First Name	Last Name	Age	School	New Grade	DOB

Consent*

I give OneCommunity permission to obtain results from my child’s test scores, grades, and additional data from my child’s school.

Signature:*

Please type your name for Signature

Signature