Education and Human Services Centers

General Outreach Family Intake Form

1 Start 2 Page 2 3 Page 3 4 Page 4 5 Complete
Select up to four choices

Student information (please enroll only one student at a time. Complete additional form for each additional child enrolled):

Student Name/Grade/School Name
Parent/Guardian Contact Info (Primary)
Please enter your phone number in the designated format with numbers and dashes (e.g. 555-555-5555)
Parent/Guardian Contact Info (Secondary)
Student contact info (usable by student)