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COLLEGE STUDENT PROFILE AND

CONSENT / RELEASE OF INFORMATION

School Year 2023-2024

LSC - University Park (999-838)


Consent to Participate:

1. I agree to participate in the Communities In Schools (CIS) program for the 2023-2024 school year. The services may include but are not limited to supportive guidance/counseling, educational support, tutoring, mentoring, enrichment activities, referrals to other agencies, and other.

2. I acknowledge that I will complete surveys and/or assessments administered by CIS to guide service planning and determine progress. I also give permission for CIS to use [on an anonymous basis] the responses to surveys and/or assessments in promotional materials and content for CIS .

3. I acknowledge that this consent is voluntary and may be revoked at any time by informing CIS staff, in writing, except that prior consent will still apply to the extent that agencies have already acted in reliance of it.

4. I agree to participate in field trips and other activities sponsored by CIS. Private transportation may be used in these and other activities.

5. I give permission for routine or emergency medical or dental treatment by any licensed medical doctor to be provided in the event of illness or accident if I am unable to do it myself.

Consent to Release of Information:

6. I give permission for CIS to provide and obtain the following information from the College: demographics, grade reports, attendance records, test scores, graduation status, class schedules, identification numbers, health-related information, special education information, interventions and services provided, and other.

7. I acknowledge that the information provided and obtained may be used to plan and adjust services for me, for tracking and reporting purposes, and to evaluate and determine the effectiveness of the CIS program.

8. I acknowledge that the records and information released under this consent will be kept confidential to the extent permitted by law and used only for the purpose indicated.

9. I acknowledge that the release of records under this consent is subject to any limitations placed by federal and state law.

10. I acknowledge that this consent allows release of data for the school year listed above. Data from this year will be retained for up to seven years and may be shared during that time for evaluation purposes or to provide services that will help me.

11. I acknowledge that the records released concerning the student may contain references to other persons (i.e., members of the student’s family).

12. I understand that the data and information collected on me including documentation of services provided to me is maintained in a secure computer database and a case file. I authorize CIS to maintain the information provided for the purposes noted above in the CIS computer database and case file.

13. I acknowledge that I have the right to inspect or obtain a copy of any record released by this consent upon request in writing to the releasing agency, subject to any applicable copying costs and legal limitations.

14. In addition, I give permission for CIS to provide and/or obtain the above information and other information noted below from the following individuals or organizations (see #14 Continued below to enter Individual/Organization).

15. I acknowledge receipt of the CIS Participant Rights.

My signature below authorizes CIS to provide the above types of information relating or referring to me and to my school and the released agents (upon appropriate request) and also authorizes CIS to obtain such information from my school.

I release Communities In Schools and its employees, volunteers, or agents from liability for accidents, injuries, or illnesses that may occur to me during my participation in the program. I understand that I am voluntarily participating in the Communities In Schools program.

Today's Date: April 21, 2026


First Student's Name
First Name*
Last Name*
Phone*
First Student's Date of Birth*
Date of Birth
Information

School Code 72-

Student ID *

ADDRESS

Address Line 1: *
Address Line 2
City: *
State: *
Zip Code:

EMERGENCY CONTACT INFORMATION

Emergency Contact's Name: *
Emergency Contact's Phone Number: *
Emergency Contact Relationship to Student: *

MEDIA RELEASE

CIS may use my image as explained herein. I understand that CIS may take and use photographs, digital or other recordings, or other images of me participating in the Program as part of its fundraising and marketing efforts. I consent to CIS's use of my image for these and similar purposes, whether in printed materials, on the Internet, or in any other medium, without any time limitation. I understand that CIS is not obligated to compensate me for such use of my image*

OPT IN FOR TELEWORK COMMUNICATION

I give my permission for CIS to contact me via text messaging using the Signal Vine Responsive SMS Platform.*

OPT IN AUDIO-VIDEO CONFERENCING PLATFORM

I give my informed consent for CIS employee to communicate with me using Audio-Video Conferencing Platform*

I am aware that I can opt out of this current communication agreement with CIS at any time.

I understand that CIS will use the checked communication platform during scheduled business hours only (8:00AM - 4:00PM).

#14 CONTINUED

Individual/Organization
Individual/Organization

ADDITIONAL STUDENT INFORMATION:

Name of High School and/or GED program
School District:
Year of HS Graduation and/or GED:
Gender*
Home Language:*
If Home Language is other, please indicate it here:
Ethnicity*
Race (select all that apply) *
American Indian/Native Alaskan
Asian
Black/African American
Native Hawaiian/Other Pacific Islander
White
Other
The Student Lives WITH: (check all that apply) *
Mother
Father
Partner or Spouse
Grandmother
Grandfather
Foster Parent
Step Parent
Other Relative
Legal Guardian
Independent
Non-Relative
Female Head of Household (Unmarried woman who pays more than 50% of costs for mom and her dependents)*
The Student Lives WHERE:*
Number of people living in the household
Assistance: (Check ALL that apply to student and family) *
Public Housing
SSI
Food Stamps
Medicaid
WIC
WIA Participant
CHIP
Financial Aid
None
Special Characteristics (Check ALL that apply) *
Migrant Family
Homeless
Foster Care
Physical Disability
Parenting/Pregnant
Natural Disaster
Active Military
Immigrant
Previously Incarcerated
First Generation College Student
Disability Services
Employed Full Time
Employed Part Time
Veteran
Unschooled, Asylee or Refugee
None
Student's Country of Origin
First Student's Signature*
Second Student's Name
First Name*
Last Name*
Student's Date of Birth*
Date of Birth
Information

School Code 72-

Student ID *

ADDRESS

Address Line 1: *
Address Line 2
City: *
State: *
Zip Code:

EMERGENCY CONTACT INFORMATION

Emergency Contact's Name: *
Emergency Contact's Phone Number: *
Emergency Contact Relationship to Student: *

MEDIA RELEASE

CIS may use my image as explained herein. I understand that CIS may take and use photographs, digital or other recordings, or other images of me participating in the Program as part of its fundraising and marketing efforts. I consent to CIS's use of my image for these and similar purposes, whether in printed materials, on the Internet, or in any other medium, without any time limitation. I understand that CIS is not obligated to compensate me for such use of my image*

OPT IN FOR TELEWORK COMMUNICATION

I give my permission for CIS to contact me via text messaging using the Signal Vine Responsive SMS Platform.*

OPT IN AUDIO-VIDEO CONFERENCING PLATFORM

I give my informed consent for CIS employee to communicate with me using Audio-Video Conferencing Platform*

I am aware that I can opt out of this current communication agreement with CIS at any time.

I understand that CIS will use the checked communication platform during scheduled business hours only (8:00AM - 4:00PM).

#14 CONTINUED

Individual/Organization
Individual/Organization

ADDITIONAL STUDENT INFORMATION:

Name of High School and/or GED program
School District:
Year of HS Graduation and/or GED:
Gender*
Home Language:*
If Home Language is other, please indicate it here:
Ethnicity*
Race (select all that apply) *
American Indian/Native Alaskan
Asian
Black/African American
Native Hawaiian/Other Pacific Islander
White
Other
The Student Lives WITH: (check all that apply) *
Mother
Father
Partner or Spouse
Grandmother
Grandfather
Foster Parent
Step Parent
Other Relative
Legal Guardian
Independent
Non-Relative
Female Head of Household (Unmarried woman who pays more than 50% of costs for mom and her dependents)*
The Student Lives WHERE:*
Number of people living in the household
Assistance: (Check ALL that apply to student and family) *
Public Housing
SSI
Food Stamps
Medicaid
WIC
WIA Participant
CHIP
Financial Aid
None
Special Characteristics (Check ALL that apply) *
Migrant Family
Homeless
Foster Care
Physical Disability
Parenting/Pregnant
Natural Disaster
Active Military
Immigrant
Previously Incarcerated
First Generation College Student
Disability Services
Employed Full Time
Employed Part Time
Veteran
Unschooled, Asylee or Refugee
None
Student's Country of Origin
Third Student's Name
First Name*
Last Name*
Student's Date of Birth*
Date of Birth
Information

School Code 72-

Student ID *

ADDRESS

Address Line 1: *
Address Line 2
City: *
State: *
Zip Code:

EMERGENCY CONTACT INFORMATION

Emergency Contact's Name: *
Emergency Contact's Phone Number: *
Emergency Contact Relationship to Student: *

MEDIA RELEASE

CIS may use my image as explained herein. I understand that CIS may take and use photographs, digital or other recordings, or other images of me participating in the Program as part of its fundraising and marketing efforts. I consent to CIS's use of my image for these and similar purposes, whether in printed materials, on the Internet, or in any other medium, without any time limitation. I understand that CIS is not obligated to compensate me for such use of my image*

OPT IN FOR TELEWORK COMMUNICATION

I give my permission for CIS to contact me via text messaging using the Signal Vine Responsive SMS Platform.*

OPT IN AUDIO-VIDEO CONFERENCING PLATFORM

I give my informed consent for CIS employee to communicate with me using Audio-Video Conferencing Platform*

I am aware that I can opt out of this current communication agreement with CIS at any time.

I understand that CIS will use the checked communication platform during scheduled business hours only (8:00AM - 4:00PM).

#14 CONTINUED

Individual/Organization
Individual/Organization

ADDITIONAL STUDENT INFORMATION:

Name of High School and/or GED program
School District:
Year of HS Graduation and/or GED:
Gender*
Home Language:*
If Home Language is other, please indicate it here:
Ethnicity*
Race (select all that apply) *
American Indian/Native Alaskan
Asian
Black/African American
Native Hawaiian/Other Pacific Islander
White
Other
The Student Lives WITH: (check all that apply) *
Mother
Father
Partner or Spouse
Grandmother
Grandfather
Foster Parent
Step Parent
Other Relative
Legal Guardian
Independent
Non-Relative
Female Head of Household (Unmarried woman who pays more than 50% of costs for mom and her dependents)*
The Student Lives WHERE:*
Number of people living in the household
Assistance: (Check ALL that apply to student and family) *
Public Housing
SSI
Food Stamps
Medicaid
WIC
WIA Participant
CHIP
Financial Aid
None
Special Characteristics (Check ALL that apply) *
Migrant Family
Homeless
Foster Care
Physical Disability
Parenting/Pregnant
Natural Disaster
Active Military
Immigrant
Previously Incarcerated
First Generation College Student
Disability Services
Employed Full Time
Employed Part Time
Veteran
Unschooled, Asylee or Refugee
None
Student's Country of Origin
Fourth Student's Name
First Name*
Last Name*
Student's Date of Birth*
Date of Birth
Information

School Code 72-

Student ID *

ADDRESS

Address Line 1: *
Address Line 2
City: *
State: *
Zip Code:

EMERGENCY CONTACT INFORMATION

Emergency Contact's Name: *
Emergency Contact's Phone Number: *
Emergency Contact Relationship to Student: *

MEDIA RELEASE

CIS may use my image as explained herein. I understand that CIS may take and use photographs, digital or other recordings, or other images of me participating in the Program as part of its fundraising and marketing efforts. I consent to CIS's use of my image for these and similar purposes, whether in printed materials, on the Internet, or in any other medium, without any time limitation. I understand that CIS is not obligated to compensate me for such use of my image*

OPT IN FOR TELEWORK COMMUNICATION

I give my permission for CIS to contact me via text messaging using the Signal Vine Responsive SMS Platform.*

OPT IN AUDIO-VIDEO CONFERENCING PLATFORM

I give my informed consent for CIS employee to communicate with me using Audio-Video Conferencing Platform*

I am aware that I can opt out of this current communication agreement with CIS at any time.

I understand that CIS will use the checked communication platform during scheduled business hours only (8:00AM - 4:00PM).

#14 CONTINUED

Individual/Organization
Individual/Organization

ADDITIONAL STUDENT INFORMATION:

Name of High School and/or GED program
School District:
Year of HS Graduation and/or GED:
Gender*
Home Language:*
If Home Language is other, please indicate it here:
Ethnicity*
Race (select all that apply) *
American Indian/Native Alaskan
Asian
Black/African American
Native Hawaiian/Other Pacific Islander
White
Other
The Student Lives WITH: (check all that apply) *
Mother
Father
Partner or Spouse
Grandmother
Grandfather
Foster Parent
Step Parent
Other Relative
Legal Guardian
Independent
Non-Relative
Female Head of Household (Unmarried woman who pays more than 50% of costs for mom and her dependents)*
The Student Lives WHERE:*
Number of people living in the household
Assistance: (Check ALL that apply to student and family) *
Public Housing
SSI
Food Stamps
Medicaid
WIC
WIA Participant
CHIP
Financial Aid
None
Special Characteristics (Check ALL that apply) *
Migrant Family
Homeless
Foster Care
Physical Disability
Parenting/Pregnant
Natural Disaster
Active Military
Immigrant
Previously Incarcerated
First Generation College Student
Disability Services
Employed Full Time
Employed Part Time
Veteran
Unschooled, Asylee or Refugee
None
Student's Country of Origin
Fifth Student's Name
First Name*
Last Name*
Student's Date of Birth*
Date of Birth
Information

School Code 72-

Student ID *

ADDRESS

Address Line 1: *
Address Line 2
City: *
State: *
Zip Code:

EMERGENCY CONTACT INFORMATION

Emergency Contact's Name: *
Emergency Contact's Phone Number: *
Emergency Contact Relationship to Student: *

MEDIA RELEASE

CIS may use my image as explained herein. I understand that CIS may take and use photographs, digital or other recordings, or other images of me participating in the Program as part of its fundraising and marketing efforts. I consent to CIS's use of my image for these and similar purposes, whether in printed materials, on the Internet, or in any other medium, without any time limitation. I understand that CIS is not obligated to compensate me for such use of my image*

OPT IN FOR TELEWORK COMMUNICATION

I give my permission for CIS to contact me via text messaging using the Signal Vine Responsive SMS Platform.*

OPT IN AUDIO-VIDEO CONFERENCING PLATFORM

I give my informed consent for CIS employee to communicate with me using Audio-Video Conferencing Platform*

I am aware that I can opt out of this current communication agreement with CIS at any time.

I understand that CIS will use the checked communication platform during scheduled business hours only (8:00AM - 4:00PM).

#14 CONTINUED

Individual/Organization
Individual/Organization

ADDITIONAL STUDENT INFORMATION:

Name of High School and/or GED program
School District:
Year of HS Graduation and/or GED:
Gender*
Home Language:*
If Home Language is other, please indicate it here:
Ethnicity*
Race (select all that apply) *
American Indian/Native Alaskan
Asian
Black/African American
Native Hawaiian/Other Pacific Islander
White
Other
The Student Lives WITH: (check all that apply) *
Mother
Father
Partner or Spouse
Grandmother
Grandfather
Foster Parent
Step Parent
Other Relative
Legal Guardian
Independent
Non-Relative
Female Head of Household (Unmarried woman who pays more than 50% of costs for mom and her dependents)*
The Student Lives WHERE:*
Number of people living in the household
Assistance: (Check ALL that apply to student and family) *
Public Housing
SSI
Food Stamps
Medicaid
WIC
WIA Participant
CHIP
Financial Aid
None
Special Characteristics (Check ALL that apply) *
Migrant Family
Homeless
Foster Care
Physical Disability
Parenting/Pregnant
Natural Disaster
Active Military
Immigrant
Previously Incarcerated
First Generation College Student
Disability Services
Employed Full Time
Employed Part Time
Veteran
Unschooled, Asylee or Refugee
None
Student's Country of Origin
Sixth Student's Name
First Name*
Last Name*
Student's Date of Birth*
Date of Birth
Information

School Code 72-

Student ID *

ADDRESS

Address Line 1: *
Address Line 2
City: *
State: *
Zip Code:

EMERGENCY CONTACT INFORMATION

Emergency Contact's Name: *
Emergency Contact's Phone Number: *
Emergency Contact Relationship to Student: *

MEDIA RELEASE

CIS may use my image as explained herein. I understand that CIS may take and use photographs, digital or other recordings, or other images of me participating in the Program as part of its fundraising and marketing efforts. I consent to CIS's use of my image for these and similar purposes, whether in printed materials, on the Internet, or in any other medium, without any time limitation. I understand that CIS is not obligated to compensate me for such use of my image*

OPT IN FOR TELEWORK COMMUNICATION

I give my permission for CIS to contact me via text messaging using the Signal Vine Responsive SMS Platform.*

OPT IN AUDIO-VIDEO CONFERENCING PLATFORM

I give my informed consent for CIS employee to communicate with me using Audio-Video Conferencing Platform*

I am aware that I can opt out of this current communication agreement with CIS at any time.

I understand that CIS will use the checked communication platform during scheduled business hours only (8:00AM - 4:00PM).

#14 CONTINUED

Individual/Organization
Individual/Organization

ADDITIONAL STUDENT INFORMATION:

Name of High School and/or GED program
School District:
Year of HS Graduation and/or GED:
Gender*
Home Language:*
If Home Language is other, please indicate it here:
Ethnicity*
Race (select all that apply) *
American Indian/Native Alaskan
Asian
Black/African American
Native Hawaiian/Other Pacific Islander
White
Other
The Student Lives WITH: (check all that apply) *
Mother
Father
Partner or Spouse
Grandmother
Grandfather
Foster Parent
Step Parent
Other Relative
Legal Guardian
Independent
Non-Relative
Female Head of Household (Unmarried woman who pays more than 50% of costs for mom and her dependents)*
The Student Lives WHERE:*
Number of people living in the household
Assistance: (Check ALL that apply to student and family) *
Public Housing
SSI
Food Stamps
Medicaid
WIC
WIA Participant
CHIP
Financial Aid
None
Special Characteristics (Check ALL that apply) *
Migrant Family
Homeless
Foster Care
Physical Disability
Parenting/Pregnant
Natural Disaster
Active Military
Immigrant
Previously Incarcerated
First Generation College Student
Disability Services
Employed Full Time
Employed Part Time
Veteran
Unschooled, Asylee or Refugee
None
Student's Country of Origin
Seventh Student's Name
First Name*
Last Name*
Student's Date of Birth*
Date of Birth
Information

School Code 72-

Student ID *

ADDRESS

Address Line 1: *
Address Line 2
City: *
State: *
Zip Code:

EMERGENCY CONTACT INFORMATION

Emergency Contact's Name: *
Emergency Contact's Phone Number: *
Emergency Contact Relationship to Student: *

MEDIA RELEASE

CIS may use my image as explained herein. I understand that CIS may take and use photographs, digital or other recordings, or other images of me participating in the Program as part of its fundraising and marketing efforts. I consent to CIS's use of my image for these and similar purposes, whether in printed materials, on the Internet, or in any other medium, without any time limitation. I understand that CIS is not obligated to compensate me for such use of my image*

OPT IN FOR TELEWORK COMMUNICATION

I give my permission for CIS to contact me via text messaging using the Signal Vine Responsive SMS Platform.*

OPT IN AUDIO-VIDEO CONFERENCING PLATFORM

I give my informed consent for CIS employee to communicate with me using Audio-Video Conferencing Platform*

I am aware that I can opt out of this current communication agreement with CIS at any time.

I understand that CIS will use the checked communication platform during scheduled business hours only (8:00AM - 4:00PM).

#14 CONTINUED

Individual/Organization
Individual/Organization

ADDITIONAL STUDENT INFORMATION:

Name of High School and/or GED program
School District:
Year of HS Graduation and/or GED:
Gender*
Home Language:*
If Home Language is other, please indicate it here:
Ethnicity*
Race (select all that apply) *
American Indian/Native Alaskan
Asian
Black/African American
Native Hawaiian/Other Pacific Islander
White
Other
The Student Lives WITH: (check all that apply) *
Mother
Father
Partner or Spouse
Grandmother
Grandfather
Foster Parent
Step Parent
Other Relative
Legal Guardian
Independent
Non-Relative
Female Head of Household (Unmarried woman who pays more than 50% of costs for mom and her dependents)*
The Student Lives WHERE:*
Number of people living in the household
Assistance: (Check ALL that apply to student and family) *
Public Housing
SSI
Food Stamps
Medicaid
WIC
WIA Participant
CHIP
Financial Aid
None
Special Characteristics (Check ALL that apply) *
Migrant Family
Homeless
Foster Care
Physical Disability
Parenting/Pregnant
Natural Disaster
Active Military
Immigrant
Previously Incarcerated
First Generation College Student
Disability Services
Employed Full Time
Employed Part Time
Veteran
Unschooled, Asylee or Refugee
None
Student's Country of Origin
Eighth Student's Name
First Name*
Last Name*
Student's Date of Birth*
Date of Birth
Information

School Code 72-

Student ID *

ADDRESS

Address Line 1: *
Address Line 2
City: *
State: *
Zip Code:

EMERGENCY CONTACT INFORMATION

Emergency Contact's Name: *
Emergency Contact's Phone Number: *
Emergency Contact Relationship to Student: *

MEDIA RELEASE

CIS may use my image as explained herein. I understand that CIS may take and use photographs, digital or other recordings, or other images of me participating in the Program as part of its fundraising and marketing efforts. I consent to CIS's use of my image for these and similar purposes, whether in printed materials, on the Internet, or in any other medium, without any time limitation. I understand that CIS is not obligated to compensate me for such use of my image*

OPT IN FOR TELEWORK COMMUNICATION

I give my permission for CIS to contact me via text messaging using the Signal Vine Responsive SMS Platform.*

OPT IN AUDIO-VIDEO CONFERENCING PLATFORM

I give my informed consent for CIS employee to communicate with me using Audio-Video Conferencing Platform*

I am aware that I can opt out of this current communication agreement with CIS at any time.

I understand that CIS will use the checked communication platform during scheduled business hours only (8:00AM - 4:00PM).

#14 CONTINUED

Individual/Organization
Individual/Organization

ADDITIONAL STUDENT INFORMATION:

Name of High School and/or GED program
School District:
Year of HS Graduation and/or GED:
Gender*
Home Language:*
If Home Language is other, please indicate it here:
Ethnicity*
Race (select all that apply) *
American Indian/Native Alaskan
Asian
Black/African American
Native Hawaiian/Other Pacific Islander
White
Other
The Student Lives WITH: (check all that apply) *
Mother
Father
Partner or Spouse
Grandmother
Grandfather
Foster Parent
Step Parent
Other Relative
Legal Guardian
Independent
Non-Relative
Female Head of Household (Unmarried woman who pays more than 50% of costs for mom and her dependents)*
The Student Lives WHERE:*
Number of people living in the household
Assistance: (Check ALL that apply to student and family) *
Public Housing
SSI
Food Stamps
Medicaid
WIC
WIA Participant
CHIP
Financial Aid
None
Special Characteristics (Check ALL that apply) *
Migrant Family
Homeless
Foster Care
Physical Disability
Parenting/Pregnant
Natural Disaster
Active Military
Immigrant
Previously Incarcerated
First Generation College Student
Disability Services
Employed Full Time
Employed Part Time
Veteran
Unschooled, Asylee or Refugee
None
Student's Country of Origin
Ninth Student's Name
First Name*
Last Name*
Student's Date of Birth*
Date of Birth
Information

School Code 72-

Student ID *

ADDRESS

Address Line 1: *
Address Line 2
City: *
State: *
Zip Code:

EMERGENCY CONTACT INFORMATION

Emergency Contact's Name: *
Emergency Contact's Phone Number: *
Emergency Contact Relationship to Student: *

MEDIA RELEASE

CIS may use my image as explained herein. I understand that CIS may take and use photographs, digital or other recordings, or other images of me participating in the Program as part of its fundraising and marketing efforts. I consent to CIS's use of my image for these and similar purposes, whether in printed materials, on the Internet, or in any other medium, without any time limitation. I understand that CIS is not obligated to compensate me for such use of my image*

OPT IN FOR TELEWORK COMMUNICATION

I give my permission for CIS to contact me via text messaging using the Signal Vine Responsive SMS Platform.*

OPT IN AUDIO-VIDEO CONFERENCING PLATFORM

I give my informed consent for CIS employee to communicate with me using Audio-Video Conferencing Platform*

I am aware that I can opt out of this current communication agreement with CIS at any time.

I understand that CIS will use the checked communication platform during scheduled business hours only (8:00AM - 4:00PM).

#14 CONTINUED

Individual/Organization
Individual/Organization

ADDITIONAL STUDENT INFORMATION:

Name of High School and/or GED program
School District:
Year of HS Graduation and/or GED:
Gender*
Home Language:*
If Home Language is other, please indicate it here:
Ethnicity*
Race (select all that apply) *
American Indian/Native Alaskan
Asian
Black/African American
Native Hawaiian/Other Pacific Islander
White
Other
The Student Lives WITH: (check all that apply) *
Mother
Father
Partner or Spouse
Grandmother
Grandfather
Foster Parent
Step Parent
Other Relative
Legal Guardian
Independent
Non-Relative
Female Head of Household (Unmarried woman who pays more than 50% of costs for mom and her dependents)*
The Student Lives WHERE:*
Number of people living in the household
Assistance: (Check ALL that apply to student and family) *
Public Housing
SSI
Food Stamps
Medicaid
WIC
WIA Participant
CHIP
Financial Aid
None
Special Characteristics (Check ALL that apply) *
Migrant Family
Homeless
Foster Care
Physical Disability
Parenting/Pregnant
Natural Disaster
Active Military
Immigrant
Previously Incarcerated
First Generation College Student
Disability Services
Employed Full Time
Employed Part Time
Veteran
Unschooled, Asylee or Refugee
None
Student's Country of Origin
Tenth Student's Name
First Name*
Last Name*
Student's Date of Birth*
Date of Birth
Information

School Code 72-

Student ID *

ADDRESS

Address Line 1: *
Address Line 2
City: *
State: *
Zip Code:

EMERGENCY CONTACT INFORMATION

Emergency Contact's Name: *
Emergency Contact's Phone Number: *
Emergency Contact Relationship to Student: *

MEDIA RELEASE

CIS may use my image as explained herein. I understand that CIS may take and use photographs, digital or other recordings, or other images of me participating in the Program as part of its fundraising and marketing efforts. I consent to CIS's use of my image for these and similar purposes, whether in printed materials, on the Internet, or in any other medium, without any time limitation. I understand that CIS is not obligated to compensate me for such use of my image*

OPT IN FOR TELEWORK COMMUNICATION

I give my permission for CIS to contact me via text messaging using the Signal Vine Responsive SMS Platform.*

OPT IN AUDIO-VIDEO CONFERENCING PLATFORM

I give my informed consent for CIS employee to communicate with me using Audio-Video Conferencing Platform*

I am aware that I can opt out of this current communication agreement with CIS at any time.

I understand that CIS will use the checked communication platform during scheduled business hours only (8:00AM - 4:00PM).

#14 CONTINUED

Individual/Organization
Individual/Organization

ADDITIONAL STUDENT INFORMATION:

Name of High School and/or GED program
School District:
Year of HS Graduation and/or GED:
Gender*
Home Language:*
If Home Language is other, please indicate it here:
Ethnicity*
Race (select all that apply) *
American Indian/Native Alaskan
Asian
Black/African American
Native Hawaiian/Other Pacific Islander
White
Other
The Student Lives WITH: (check all that apply) *
Mother
Father
Partner or Spouse
Grandmother
Grandfather
Foster Parent
Step Parent
Other Relative
Legal Guardian
Independent
Non-Relative
Female Head of Household (Unmarried woman who pays more than 50% of costs for mom and her dependents)*
The Student Lives WHERE:*
Number of people living in the household
Assistance: (Check ALL that apply to student and family) *
Public Housing
SSI
Food Stamps
Medicaid
WIC
WIA Participant
CHIP
Financial Aid
None
Special Characteristics (Check ALL that apply) *
Migrant Family
Homeless
Foster Care
Physical Disability
Parenting/Pregnant
Natural Disaster
Active Military
Immigrant
Previously Incarcerated
First Generation College Student
Disability Services
Employed Full Time
Employed Part Time
Veteran
Unschooled, Asylee or Refugee
None
Student's Country of Origin
County
County*
Parent or Guardian's Email Address
Email
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Information

School Code 72-

Student ID *

ADDRESS

Address Line 1: *
Address Line 2
City: *
State: *
Zip Code:

EMERGENCY CONTACT INFORMATION

Emergency Contact's Name: *
Emergency Contact's Phone Number: *
Emergency Contact Relationship to Student: *

MEDIA RELEASE

CIS may use my image as explained herein. I understand that CIS may take and use photographs, digital or other recordings, or other images of me participating in the Program as part of its fundraising and marketing efforts. I consent to CIS's use of my image for these and similar purposes, whether in printed materials, on the Internet, or in any other medium, without any time limitation. I understand that CIS is not obligated to compensate me for such use of my image*

OPT IN FOR TELEWORK COMMUNICATION

I give my permission for CIS to contact me via text messaging using the Signal Vine Responsive SMS Platform.*

OPT IN AUDIO-VIDEO CONFERENCING PLATFORM

I give my informed consent for CIS employee to communicate with me using Audio-Video Conferencing Platform*

I am aware that I can opt out of this current communication agreement with CIS at any time.

I understand that CIS will use the checked communication platform during scheduled business hours only (8:00AM - 4:00PM).

#14 CONTINUED

Individual/Organization
Individual/Organization

ADDITIONAL STUDENT INFORMATION:

Name of High School and/or GED program
School District:
Year of HS Graduation and/or GED:
Gender*
Home Language:*
If Home Language is other, please indicate it here:
Ethnicity*
Race (select all that apply) *
American Indian/Native Alaskan
Asian
Black/African American
Native Hawaiian/Other Pacific Islander
White
Other
The Student Lives WITH: (check all that apply) *
Mother
Father
Partner or Spouse
Grandmother
Grandfather
Foster Parent
Step Parent
Other Relative
Legal Guardian
Independent
Non-Relative
Female Head of Household (Unmarried woman who pays more than 50% of costs for mom and her dependents)*
The Student Lives WHERE:*
Number of people living in the household
Assistance: (Check ALL that apply to student and family) *
Public Housing
SSI
Food Stamps
Medicaid
WIC
WIA Participant
CHIP
Financial Aid
None
Special Characteristics (Check ALL that apply) *
Migrant Family
Homeless
Foster Care
Physical Disability
Parenting/Pregnant
Natural Disaster
Active Military
Immigrant
Previously Incarcerated
First Generation College Student
Disability Services
Employed Full Time
Employed Part Time
Veteran
Unschooled, Asylee or Refugee
None
Student's Country of Origin
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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