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Foothills Education Charter High School Registration Survey
Student Online registration form
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* Indicates required question
Email
*
Your email
Have you attended Coastal Plains, Foothills, or Mountain Education Charter HS before?
yes
no
Clear selection
If yes, what was the last month you attended?
MM
/
DD
/
YYYY
What Foothills Charter H.S. site would you like to attend? (required)
*
Bibb County (opening January 2020)
Student First Name (required)
*
Your answer
Student Middle Name
Your answer
Student Last Name (required)
*
Your answer
Maiden Name
Your answer
Sex (required)
*
female
male
Date of Birth (required)
*
MM
/
DD
/
YYYY
City of Birth (required)
*
Your answer
State or Nation of Birth (required)
*
Your answer
Home Street Address or Post Office Box (required)
*
Your answer
City (required)
*
Your answer
State (required)
*
Your answer
Zip Code (required)
*
Your answer
Student Cell Phone
Your answer
Home Phone (required - if no home phone, re-enter cell phone
*
Your answer
Student Email Address (required, if no email, enter
noemail@gmail.com
)
*
Your answer
Are you Hispanic/Latino? (required)
*
yes
no
Race/Ethnicity (required. check all that apply, must check at least one)
*
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
Required
Mother's First Name
Your answer
Mother's Last Name
Your answer
Mother's Phone
Your answer
Mother's Email
Your answer
Father's First name
Your answer
Father's Last Name
Your answer
Father's Phone
Your answer
Father's Email
Your answer
With whom do you live? (required)
*
Mother
Father
Both Parents
Self
Other (list below)
Other Contact First Name
Your answer
Other Contact Last Name
Your answer
Other Contact Phone Number
Your answer
Other Contact Email Address
Your answer
Do you take any medication(s) while at school? (required)
*
yes
no
List Medications Taken
Your answer
Emergency Contact Name (required)
*
Your answer
Emergency Contact Phone (required)
*
Your answer
Are you employed? (required)
*
yes
no
If yes, list place of employment.
Your answer
Employer Phone
Your answer
Do you have children?
yes
no
Clear selection
If yes, how many.
Your answer
Do you have allergies? (required)
*
yes
no
If yes, what are you allergic to?
Your answer
Are you diabetic? (required)
*
yes
no
Send me a copy of my responses.
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