Scholar Application

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* Affiliate

* Center

* Scholar First Name

* Scholar Last Name

* Current Grade

School ID Number

* Date of Birth

* Gender

* Ethnicity/Race

* Does your child receive free/reduced lunch?

* Language Spoken at Home

* How did you hear about us?

Health Insurance Carrier

Health Insurance Policy Number

Student's Current Medications

List Known Allergies

List Physical Conditions

* Select Current School

Scholar Application

* Emergency Contact One

Last Name

Emergency Contact Two

Last Name

* Relationship to Applicant

Relationship to Applicant

Phone

* Phone

By signing below, I confirm the above information is accurate.

If my child is accepted into Higher Achievement, I also grant Higher Achievement:

Permission to obtain copies of my child’s report cards and standardized test scores, and individual educational plans or records if applicable, from their school at anytime(s) until s/he/they completes grade twelve Whether or not my child is accepted into Higher Achievement.
Permission for my child to ride in a vehicle driven by Higher Achievement staff or volunteers for Higher Achievement related activities
- Note: For any KIPP DC site, including our DC Ward 8-KIPP AIM site, KIPP prohibits any scholar from riding in a vehicle with Higher Achievement staff, so this does not apply to KIPP DC students.

Permission to track aggregate Scholar data and share the results.

I also agree to waive any claims or lawsuits against Higher Achievement that may arise in connection with my child's participation in the program. To the extent allowed by law, this waiver includes any claims of negligence or other allegations of wrongdoing by Higher Achievement.

* I give permission for my child to be interviewed, photographed, and/or filmed as part of their participation in Higher Achievement. I also authorize Higher Achievement and its partners to publicly share these photos, videos, and/or any work created by my child while attending Higher Achievement programming and events.

I give permission for my child to be interviewed, photographed, and/or filmed as part of their participation in Higher Achievement. I also authorize Higher Achievement and its partners to publicly share these photos, videos, and/or any work created by my child while attending Higher Achievement programming and events.

Agree

Disagree

Date

* Parent/Guardian 1 First Name

* Parent/Guardian 1 Last Name

* Relationship to Applicant

* Employer

Home/Other Telephone Number

* Mobile Telephone Number

* Email

Work Telephone Number

* Highest level of education achieved?

* Street Address

Address Line 2

* City

* State

* Zip Code

* Household Income

Student lives with:

Parent/Guardian 1

Parent/Guardian 2

Both (same address)

Both (different addresses)

Primary Contact

Yes

Scholar Information

Filled out by HA STAFF

HA STAFF NAME

Parent/Guardian 2 First Name

Parent/Guardian 2 Last Name

P2 Relationship to Applicant

Parent/Guardian 2 Home Address

City

State

Zip Code

Employer

Home/Other Telephone Number

Work Telephone Number

Parent/Guardian 2 Mobile Phone

Highest level of education achieved?

Parent/Guardian 2 Information

Parent/Guardian 1 Information

Emergency Contact

Staff will contact primary and secondary parent/guardian first in an emergency. Please list at least one additional emergency contact who is not the primary parent/guardian.

To be completed by parent or guardian

I hereby give my permission for Higher Achievement staff or volunteers to seek medical attention or administer first aid in the event of an emergency or to administer any medications that my child is taking. I also agree to assume financial responsibility for such treatment.

Parent Signature