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PB REACH.U Enrollment 2020-21
PB REACH.U will be 100% online for winter/spring 2021, using Google Classroom and Google Meets.
Please fill out entire form for each child enrolling in the program.
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* Indicates required question
Email
*
Your email
Child's Name: Last, First
*
Your answer
Parent/Caregiver Email Address
*
Your answer
Grade Level:
*
9th
10th
11th
12th
Parent/Guardian Name(s)
*
Your answer
Preferred Contact Phone Number #1
*
Your answer
Preferred Contact Phone Number #2
*
Your answer
Mailing Address
*
Your answer
Emergency Contact #1 : Name and Phone Number
*
Your answer
Emergency Contact #2: Name and Phone Number
*
Your answer
Student Birth Date
*
MM
/
DD
/
YYYY
Can this child have a photographed published?
*
Yes
No
Grant Required Questions
REACH.U uses the following information for the sole purpose of grants and fundraising. All information will remain confidential and anonymous.
Student Ethnicity
White/Caucasian
American Indian
Asian
Black/African American
Hispanic
Two or More Races
Prefer not to answer
Clear selection
Gender
Female
Male
Prefer not to say
Clear selection
Is the student eligible for free and reduced lunch at school?
Yes
No
Prefer not to say
Clear selection
Does the student have an IEP or 504 plan?
Yes
No
Prefer not to say
Clear selection
Please select the type of household the student resides in the majority of the time:
ONE biological parent in the home
BOTH biological parents in the home
Grandparents/Kinship Care
Foster Child
Prefer not to say
Other:
Clear selection
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