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Student Registration
Student Information
Student's Full Name
Date of Birth
Grade (K–5)
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
School
Teacher (optional)
Home Address
Parent / Guardian Information
Parent / Guardian 1
Relationship
Phone
Email
Parent / Guardian 2 (optional)
Relationship
Phone
Email
Emergency Contact
Name
Relationship
Phone
Authorized Pick-Up
Authorized Person 1
Authorized Person 2
Authorized Person 3
Program Interests
Select all that apply
Tutoring Pods
Homework Help
Math Enrichment
Music Lessons
SEL Change Makers
Family Engagement
Other Academic Support
What would you most like your child to gain from the program?
Student Support Information
Primary Language Spoken at Home
Does the student receive ESL / ENL support?
Yes
No
Not Sure
Allergies, medical needs, accessibility needs, or accommodations (optional)
Anything else you would like our staff to know about your child?
Dismissal / Pick-Up
Dismissal Method
Parent / Guardian Pick-Up
Authorized Adult Pick-Up
Other
If other, please explain
Consents & Acknowledgments
I confirm that the information provided on this form is accurate to the best of my knowledge.
I understand that I must keep Global Equity Education informed of changes to contact or pick-up information.
In an emergency, I authorize program staff to contact emergency services when reasonably necessary.
Photo / Media Permission
YES — My child may be photographed or video recorded for program communications.
NO — Please do not photograph or video record my child.
Parent / Guardian Signature
Printed Name
Date
Electronic Signature
SUBMIT REGISTRATION
