PARTNERSHIP MEMBERSHIP APPLICATION 2020-2021
STUDENT DEMOGRAPHIC INFORMATION
SSN #*
Student Name*
First Name Last Name
Date of Birth*
Month Day Year
Race / Ethnicity*
Gender*
Parent #1 Name*
First Name Last Name
Parent #1 Phone Number*
Area Code Phone Number
Parent #1 Employment Info*
Parent #2 Name
First Name Last Name
Parent #2 Phone Number
Area Code Phone Number
Parent #2 Employment Info
Mailing Address*
Street Address
Street Address Line 2
City State
Zip Code
Single Parent ?*
Number in Household*
Including Parent(s)
By checking the following, permission is given for for the following
My child has my permission to be used in public relations materials. My child has my permission to participate in Club activitites.
Signature*
Clear
FOR OFFICE USE ONLY
Membership Number
Expiration Date
Status
Renewal / New Member
Processed By:
Should be Empty: