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REGISTER FOR HOPE ACADEMY'S FAMILY PORTAL AND ENROLL IN CLASSES
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Referral Information
How did you hear about us?
ARYSE
Casa San Jose
East Liberty Presbyterian Church
Facebook
Flyer
Friend
Instagram
Internet Search
Other
Pittsburgh Ballet Theatre
Referral
Returning Family
The Latino Community Center
Website
Referral Name
Family Information
Family/Account Name Last Name
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Where do you live?
Home Address
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City
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State
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AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NE
NC
ND
NH
NJ
NM
NY
NV
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
PR
VI
Zip
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Primary Phone
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Additional Info
Emergency Contact Name & Phone (Not Contact #1 or #2)
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Returning from 2023-2024
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Low-Income? <150% Fed Poverty
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Contact #1
Parent/Guardian #1 First Name
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Last Name
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Relationship
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Aunt
Big Brother/Big Sister
Caregiver
Father
Foster Parent
Grandfather
Grandmother
Guardian
Mother
Parent
Self (for events)
Uncle
How Can We Contact You?
Home Phone
Work #
Cell #
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Portal Access (your email is your login)
Email
*
(Emails are kept confidential)
Confirm Email
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Portal Account Password
Confirm Portal Account Password
Who is your employer?
Employer
Employer Phone
Employer Notes
Contact #2
Parent/Guardian #2 First Name
Last Name
Relationship
*
Aunt
Big Brother/Big Sister
Caregiver
Father
Foster Parent
Grandfather
Grandmother
Guardian
Mother
Parent
Self (for events)
Uncle
How can we contact you?
Home Phone
Work #
Cell #
Email
(Emails are kept confidential)
Confirm Email
Student #1
Student's First Name
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Last Name
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Birth Date
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Cell #
Additional Info
Student Email
School
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Grade Level
*
10th grade
11th grade
12th grade
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
Adult
college-junior
college-senior
kindergarten
pre-K
preschool
Accommodations
Allergies (Leave blank if NONE)
Medications (Leave blank if NONE)
Student's Race or Ethnicity
*
Student's Personal Pronoun
*
Student #2
(Show-Hide Details)
Student's First Name
*
Last Name
*
Birth Date
*
Cell #
Additional Info
Student Email
School
*
Grade Level
*
10th grade
11th grade
12th grade
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
Adult
college-junior
college-senior
kindergarten
pre-K
preschool
Accommodations
Allergies (Leave blank if NONE)
Medications (Leave blank if NONE)
Student's Race or Ethnicity
*
Student's Personal Pronoun
*
Student #3
(Show-Hide Details)
Student's First Name
*
Last Name
*
Birth Date
*
Cell #
Additional Info
Student Email
School
*
Grade Level
*
10th grade
11th grade
12th grade
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
Adult
college-junior
college-senior
kindergarten
pre-K
preschool
Accommodations
Allergies (Leave blank if NONE)
Medications (Leave blank if NONE)
Student's Race or Ethnicity
*
Student's Personal Pronoun
*
Student #4
(Show-Hide Details)
Student's First Name
*
Last Name
*
Birth Date
*
Cell #
Additional Info
Student Email
School
*
Grade Level
*
10th grade
11th grade
12th grade
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
Adult
college-junior
college-senior
kindergarten
pre-K
preschool
Accommodations
Allergies (Leave blank if NONE)
Medications (Leave blank if NONE)
Student's Race or Ethnicity
*
Student's Personal Pronoun
*
Student #5
(Show-Hide Details)
Student's First Name
*
Last Name
*
Birth Date
*
Cell #
Additional Info
Student Email
School
*
Grade Level
*
10th grade
11th grade
12th grade
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
Adult
college-junior
college-senior
kindergarten
pre-K
preschool
Accommodations
Allergies (Leave blank if NONE)
Medications (Leave blank if NONE)
Student's Race or Ethnicity
*
Student's Personal Pronoun
*
Add Another Student
Required Policies
(Show-Hide Details)
I Agree to All of the Above
Enter your Full Name
*
November 23, 2024
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Card Nickname
Name as it appears on card
Address Line 1
Address Line 2
City
State
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
PR
VI
Zip