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Our House Registration Form
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* Indicates required question
Student Name
*
Your answer
Pronouns
She / her
He / him
They / them
Clear selection
Student Phone Number
*
Your answer
Student Email Address
*
Your answer
Student's Physical Address
Your answer
Preferred method of communication
Text Message
WhatsApp Message
Email
Phone Call
Clear selection
Date of birth
*
MM
/
DD
/
YYYY
Student ID #
*
Your answer
Grade
Freshman
Sophomore
Junior
Senior
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Student's G
uidance Counselor
Christopher Miemiec
Courtney Foster
Yulia Chumak
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What after school activities do you participate in?
Your answer
Parent or Guardian's Name
Your answer
Parent or Guardian Relationship
Mother
Father
Guardian
Other:
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Parent or Guardian's Phone Number
Your answer
Parent or Guardian's Email Address
Your answer
Emergency contact
if different than Parent / Guardian
Your answer
If we contact home, will interpreter services be needed?
Yes
No
Clear selection
If yes, what is your preferred language?
Spanish
Portuguese
Bulgarian
Other:
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# people in your household
1
2
3
4
5
6
7
8 or more
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Is anyone in your household handicapped or disabled?
Yes
No
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Before COVID, were you (or your siblings) eligible for free or reduced cost lunch?
*
Yes
No
Race
*
Asian
Asian and White
American Indian / Alaskan Native
American Indian / Alaskan Native and White
American Indian/Alaskan Native and Black/African American
Black/African-American
Black/African-American and White
Native Hawaiian/Pacific Islander
White
Other Race(s)
Are you Hispanic / Latino?
*
Yes
No
Option 3
Do you have any food allergies or intolerances? (check all that apply)
*
No allergies or intolerances
Milk
Eggs
Tree nuts (almonds, cashews, macadamia nuts, pistachios, pine nuts, walnuts)
Peanuts
Wheat
Soy
Shellfish
Fish
Mushrooms
Other:
Required
Do you follow a specific diet?
*
No
Gluten free
Vegetarian
Vegan
Kosher
Other:
Required
Do you have any of the following medical conditions?
*
No
Allergy to insect sting / bite (e.g. Bee sting, etc)
Asthma
Diabetes
Seizures
Other:
Required
Please may we include you in any photos or videos
*
Yes
No
Thank you for registering for Our House! We look forward to having you join us.
If you have any questions, please email us at ourhousenantucket@gmail.com
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