Summer 2023 Advancement Academy Registration Form

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Please complete this form by May 19, 2023. Should you have any questions, please contact Maureen Duncan at 765-393-8625 or mduncan@mhcmcindiana.org

Student's First Name *

Student's Last Name *

Student's Grade *

Kindergarten

Student's School *

Anderson Elementary

Eastside Elementary

Edgewood Elementary

Erskine Elementary

Tenth Street Elementary

Valley Grove Elementary

Anderson Intermediate

Highland Middle

Select T Shirt Size *

XXL

Required

Select Youth or Adult Size *

Youth

Adult

Parent/Guardian Name *

Phone Number 1 (ex. 765-123-4567) *

Phone Number 2 (ex. 765-123-4567) *

Parent/Guardian Email Address *

Emergency Contact Name & Relationship to Student *

Emergency Contact Phone Number (ex. 765-123-4567) *

Does your student have any allergies? *

Yes

If yes, please list allergies: *

Is your student prescribed medications during school hours? If yes please list *

Select One: My student will *

Will need bus transportation during the Academy

Will be Parent Pick-up for the Academy

Student Address *

By submitting this form, I hereby give the Minority Health Coalition of Madison County permission to use my child’s photo for publicity purposes. I also, waive the right to review the finished product that maybe used with the student's photo. I hereby give consent and permission for the Minority Health Coalition to access my student's school based performance data including test scores, grades, etc. *

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