Application Order Number STUDENT INFORMATION First Name * Middle Name Last Name * Date of Birth * Current Age * 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21+ Gender * Female Male Transgender Do not identify as female, male, or transgender Street Address * Street Address line 2 City * State * Select a State/ProvinceAlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces AmericasArmed Forces EuropeArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUnited States Minor Outlying IslandsUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip code * Email Home number * Cell number * Facebook How many years have you been coming to THE POINT? * How did you hear about us? * Guidance Counselor Advertisement Parent Principal or Teacher The Point CDC Staff Member Alumni or Current Students Other Family Information Total number of people living in the household: Who do you live with? * Parent/Guardian's First Name * Parent/Guardian's Last Name * Parent/Guardian's Place of Employment * Parent/Guardian's Phone * Is this a cell phone? * Yes No Primary Language spoken * English Spanish N/A Add another parent or guardian Yes No Is this your Emergency Contact * Yes No School Information Name of School * Grade * Kindergarten First grade Second grade Third grade Fourth grade Fifth grade Sixth grade Seventh grade Eighth grade Ninth grade (Freshman) Tenth grade (Sophomore) Eleventh grade (Junior) Twelfth grade (Senior) GED program Other What type of education programming are you enrolled in? * Regular Education Special Education (IEP) English as a Second Language Medical Information Physical must be less than 1 calendar year - nothing before will be accepted Family Clinic or Hospital * Clinic or Hospital Phone * Do you know Physician Name * Yes No Medication currently being taken by participant Allergies of participant Other Medical Condition Medical Insurance Policy# The Point Programs I'm interested in the following programs Are you filling this out with your parent? * Yes No Read Parent & Participant Agreement Today's date *