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

Zipcode

Second Parent/Legal Guardian Contact Information

First Name

Last Name

Phone

Email Address

Address Line 1

Address Line 2

City

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?

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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