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PWC Student Interest Form
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First Name
Your answer
Last Name
Your answer
Nickname (if applicable)
Your answer
Current Grade
Your answer
Age
Your answer
DOB
MM
/
DD
/
YYYY
PUSD Student ID #
Your answer
Home Address (# Street, city)
Your answer
Home phone
Your answer
Parent/Guardian Name
Your answer
Parent/Guardian Cell Phone Number
Your answer
Student Cell Phone Number
Your answer
Ethnicity
Your answer
Home Language
Your answer
Does the student have any allergies? If so, please describe:
Your answer
Does the student have any major health issues? If so, please describe:
Your answer
Program of interest:
Community Service
After-school Enrichment
Other:
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EMERGENCY CONTACT INFORMATION
First and Last Name
Your answer
Relationship to Student
Your answer
Phone number
Your answer
Address
Your answer
Thank you for your interest! We will contact you soon!
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