9%
Indian Education Center Intake Survey
Parent or Legal Guardian Information
Parent/Legal Guardian Contact Information
First Name
Last Name
Phone
Email Address
Address Line 1
Address Line 2
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
District of Columbia
Zipcode
Second
Parent/Legal Guardian Contact Information
First Name
Last Name
Phone
Email Address
Address Line 1
Address Line 2
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
District of Columbia
Zipcode
Which two people would you like to be contacted in the case of an emergency?
Myself
The second parent/legal guardian listed above
Someone else (You will be asked to list their contact information below)
Emergency Contact/Release Information
First Name
Last Name
Phone
Work Phone
Relationship to Child
What is the best way to contact you/the emergency contacts in an emergency?
Phone
Text Message
Email
Please select any household types that apply to you.
Female Head of Household
Male Head of Household
2 Parent Household
Non-related Adults with Children
Multi-Generational Household
Other
How many people live in your household
including yourself
?
-- Select --
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Please select your housing situation.
Own
Rent
Homeless (This includes couchsurfing)
Other
Do you live on a Reservation or Rancheria?
Yes
No
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