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Parent Information
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Address:
City:	Zip	County:
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Children in Home

Name	Age	DOB	Grade	School/Daycare

Parent/Student Services

What type of services are you interested in? Check all that apply.

Pre-K (birth-5yrs)	Read, Set, Read (K-5th)	Operation Middle (6th – 8th)	Race to 100 (9th -12th)

College Prep	Workshops	Entrepreneur Coach	EOG/EOC Resources

Scholarships	Tutorials	Career Prep	Prayer

Attend Meeting (ex. IEP/Section 504/Conference)

Other:	Other:	Other:	Other:

Comments:

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Donation Type: Quarterly (9wks) Annually Community Service

AGI: ______ VERIFICATION TYPE: __________VERIFIED BY: ________________________

County: LEA CODE:

Internal Audit by: Date: __________