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San Francisco Achievers Student Intake Form
Student Intake Form
Step 1 of 3 - Section 1: Student Information
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San Francisco Achievers High School support description:
San Francisco Achievers High School support program is being offered at the high School your child attends. SF Achievers is a youth development program that supports African American student development in areas focusing on College Awareness, Career Exploration, Financial Responsibility, Cultural Identity, Identity Formation, along with Health and Wellness. Within each of these areas, SF Achievers will encourage students to explore, educate, and empower individual learning outcomes designed to develop personal and academic achievement. An SF Achievers High School Advisor will work with the student during school hours and possibly outside of the school day, with parent/guardian consent. There will also be events hosted by SF Achievers that you are more than welcome to attend. You will receive more information about our events throughout the year. For your child to participate in this program, there are several expectations your child must commit to. Respect your advisor as well as the other faculty, staff, peers and administrators present at your school. Stay on task with your classwork and homework. Lastly, students must behave in a manner that is in their best interest as well as in the best interest of others.
Section 1: Student Information
Name
First
Middle Initial
Last
Date of Birth
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Student ID
Gender
M
F
Other
High School
Homeroom/Advisory
Grade
*
9th/Freshman
10th/Sophmore
11th/Junior
12th/Senior
Student's Email Address
Home Phone
Cell Phone
Text Message Ok?
Yes
No
Choose Primary Phone
Home
Cell
Student's Primary Address
Street Address
Apt. #
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Ethnic Background (check all that apply)
African American
Hispanic/Latino
White/Caucasian
Asian
Mixed
Other
Do you live with:
Both Parents
One Parent
Grandparent(s)
Guardian
Foster
Other
Language(s) spoken in home:
English Only
English and other languages(s)
Are you enrolled in ELL Class
Yes
No
Parent/Legal Guardian's Name
First
Last
Relationship To Student
Parent/Legal Guardian Email Address
Parent/Legal Guardian Home Phone
Parent/Legal Guardian Work Phone
Parent/Legal Guardian Cell Phone
Text Message Ok?
Yes
No
Choose Primary Phone
Home Phone
Work Phone
Cell Phone
Section 2: Authorization
San Francisco Achievers and/or various other media may choose to take pictures or videotape participants in SFA Activities. These images may be used for SFA Displays, brochures, newsletters, archives, our website, news releases and publicity.
Untitled
I give permission for my child to participate in the SFA High School support program.
I hereby grant San Francisco Achievers permission to take and reproduce photographs and videotapes for publication.
Student Signature
My signature affirms my intention to fully participate.
Date
MM
DD
YYYY
Parent/Legal Guardian Signature
My signature affirms my support of my student to participate.
Date
MM
DD
YYYY
Name
This field is for validation purposes and should be left unchanged.