Word Squad Registration Form

Click here for the printed version

Student Name *
Student Name
Gender *
Date of Birth *
Date of Birth
Teacher Name *
Teacher Name
English Teacher for Middle and High School
Have you participated in 916 Ink before? *
Which of the following best describes the participant's race or ethnicity *
Other
What language is spoken most of the time at home? *
(select one)
Other
Home Address: *
Home Address:
Parent/Guardian Phone #1 *
Parent/Guardian Phone #1
Parent/Guardian Phone #2
Parent/Guardian Phone #2
Emergency Contact #1 *
Emergency Contact #1
Emergency Contact #1 *
Emergency Contact #1
Emergency Contact #2
Emergency Contact #2
Emergency Contact #2
Emergency Contact #2
Authorized Person(s) to Pick-up Students
Authorized Person(s) to Pick-up Students
Phone #
Phone #
Phone #
Phone #
List anyone who specifically cannot pick up your child
List anyone who specifically cannot pick up your child
Phone #
Phone #
Phone #
Phone #
Release of Liability *
Permission for Medical Treatment *
Photography Release *
(We do not reveal last names in our publicity and it is rare that we release first names).
Publishing Release *