An Achievable Dream HENRICO COUNTY Student Information Form
We are delighted you are interested in your student attending the Achievable Dream program.  This sheet is to be completed by parents / guardians for each student so that we may have accurate records for the students.  This sheet will become a permanent part of his/her records, so it is imperative that the information is correct. Please complete this form for each student prior to attending your informational meeting.
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What is your email address? *
Student -Last Name *
Student -First Name *
Student -Middle Initial *
Birthday *
MM
/
DD
/
YYYY
Student Number *
Gender *
Present School *
Present Grade *
Number of Siblings -Sisters *
Number of Siblings -Brothers *
Number of Siblings  in AAD *
List the First Name, Last Name and School ID# of Each Sibling in The Achievable Dream Program:
Name of Parent or Guardian Having Legal Custody: *
Relationship to Student *
Name of Parent or Guardian Having Legal Custody:
Relationship to Student
Are you a single Parent? *
Do you live in? *
(If other, please explain)
Street Address *
City *
State *
Zip Code *
Home Phone Number
(000) 000-0000
Work Phone Number
(000) 000-0000
Cell Phone Number
(000) 000-0000
Who does the student reside with? *
(If Other Specify Name and Relationship)
Highest Grade completed by Mother *
Highest Grade completed by Father *
Does the Child Participate in the Free Lunch Program? *
Does the Child Participate in the Reduced Lunch Program? *
How Many People Live in Your Household? *
Does your child have an individual education plan (IEP) or have other accommodation needs? *
If yes, under what category is he/she served?
Student Uniform Size *
Did someone refer you to the program? If so, please list their name.
How did you hear about An Achievable Dream? *
You will need to submit a copy of your child's most recent report card. This is necessary to apply, unless your child currently attends An Achievable Dream Academy. You can email the report card to recruitment@achievabledream.org or fax to (757) 873-4887. Please indicate if you will email the report card or fax it. *
Agreement: *
I agree to permit An Achievable Dream, Inc. access to all needed academic and discipline records of my son / daughter that Achievable Dream, in its sole discretion, deems necessary.  I give my permission for my child to be photographed and / or participate in any Achievable Dream publicity. Information collected on this form will be for Achievable Dream’s internal use only and will not be given or shared with anyone. We will use this data in our selection process and if your child is selected, the data will be used for informational purposes only (for example, uniforms).  
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