Enrollment Form If you are human, leave this field blank. Contact Information Parent Attending HSN * Cell Phone * Email * Address * City * State & Zip * Church Affilation * Religious Preference * Select Christian Church/Churches of Christ Baptist Methodist Assembly of God Pentacostal Morman Other If Other Please Specify: Marital Status * Select Married Divorced Single WIdow Separated Have you or your spouse ever been arrested * Yes No If yes, please explain when, why, and outcome Year started Schooling Family Business/Services Hobbies/Interest/Teaching Experience * End Section Areas interested in serving/contributing at Co-op: (subjects to teach, activities/committees to plan/serve on, talents, etc.) * Hours Attending (check all that apply) * 9 a.m. 10 a.m. 11 a.m. 12 p.m. 1 p.m. 2 p.m. Parent Information Mother's First/Last: (if different from above) Cell Phone (if different from above) Email (if different from above) Street address: (if different from above) City (if different from above) State & Zip (if different from above) Father's First/Last: * Cell Phone Email Street address: (if different from above) City (if different from above) State & Zip (if different from above) End Section Student Information (those planning to attend HSN) Student Name (first & last) * Birthdate * Grade * Phone (if different from above) Email (if different from above) Health/Behavior/Learning challenges Student Name (first & last) Birthdate Grade Phone Email Health/Behavior/Learning challenges Student Name (first & last) Birthdate Grade Phone Email Health/Behavior/Learning challenges Student Name (first & last) Birthdate Grade Phone Email Health/Behavior/Learning challenges End Section Submit
