Feed Your Brain, Alimenta tu Cerebro Registration Forms_English

School Lunch Location (Which school will you be attending for the FYB program?):*

Year*

Please enter a number from 2020 to 2030.

Mr./Mrs. Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Alt. Phone Number

Email

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 (Click plus sign (+) to add more children)*

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.

Photo/Video Image Release*

I hereby consent to and authorize the use and reproduction by OneCommunity, or anyone authorized by OneCommunity of any and all photographs/video images that have been taken of me this day for any purpose, without compensation to me. All negatives, positives, digital files, together with the prints, are the property of OneCommunity. OneCommunity reserves the right to use these photographs in any of its print or electronic publication for any length of time. I hereby acknowledge that I am 18 years of age or older and have read and understood the terms of this release.

Date*

Signature:*

Please type your name for Signature

Signature