School or Program Authorization Code:

About You and Your Household

Please fill in the following items to the best of your ability. Note: items with a * are required.

First Name *  
Middle Initial
Last Name *  
Street Address
City
State
Zip Code
Phone Number
Your Date of Birth *  
Your Gender *  
What grade are you in this school year? *  
Your Email Address

Parent or Guardian to receive your Encouragement Report, please provide his/her information below (this is optional):
Parent/Guardian First Name
Parent/Guardian Last Name
Street Address of Parent/Guardian (if different from above)
City
State
Zip Code
Parent/Guardian Email Address

If you would like a second parent/guardian to receive your Encouragement Report, please provide his/her information below (this is optional):
Second Parent/Guardian First Name
Second Parent/Guardian Last Name
Street Address of Second Parent/Guardian (if different from above)
City
State
Zip Code
Parent/Guardian Email Address
   
What is the primary language spoken in your home? (select one)
What best describes your racial and ethnic identity? (select all that apply)?
What is the highest level of education completed by anyone living in your household?
What grades do you usually receive on your report card?
Living arrangements--you live...

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