Voices of the West | Blanding

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Student First Name

Student Last Name

Student Email

Student Phone

Home Address

City

State

ZIP Code

Student Birthdate (MM-DD-YY)

Gender Identity

Pronouns

She/Her/Hers He/Him/His They/Them/Theirs Prefer Not to Disclose

Race/Ethnicity

What is the PRIMARY language spoken in your home.

Other languages spoken at home (mark n/a if not applicable)

School (If Home School, write "Home School")

Grade

Do you qualify for free or reduced lunch?

Yes No I don't know

Please select the annual income for your family from the list below.

Do you live on your own?

Yes No

How many people live in your household?

Do you have internet access at home?

Yes No

What type of device do you use to access the internet?

Do you need additional resources or services?

Yes No

If yes, please describe the additional resources you need (transportation, food access, academic support, job opportunities, mental/emotional, health, other).

Guardian/Emergency Contact First Name

Guardian/Emergency Contact Last Name

Guardian/Emergency Contact Email

Guardian/Emergency Contact Phone

How did you hear about Spy Hop?

What skills do you hope to learn in this class?

Would you like to receive Spy Hop emails?

Yes, please send me Spy Hop general and event updates.

I consent to my/my child's work being displayed in the community, submitted to festivals, and other public venues.

I consent to Program staff photographing, videotaping, making sound recordings or screen capturing of me/my child to advertise Spy Hop programs, including public display.

I consent to Spy Hop collecting information from my child in order to evaluate its Program, including interviews, observations, surveys, and other class activities and materials. I understand that my child will complete a confidential survey about his or her attitudes and opinions as part of this evaluation. I understand that the information obtained will be analyzed and that my child’s name will be withheld for confidentiality purposes. I understand that this information will be part of a larger evaluation and only the evaluation team and program staff will have access to this confidential information.