Contact Information Form

Contact Information Form - College Bound

Note: This form is for College Bound students and their parents/guardians to provide their contact information with the program. Providing your cell phone number in this form will also subscribe you to our OtterBot texting program. If you were enrolled in College Bound during middle school, please complete the form so we can keep you updated with resources and important information while you are in high school. We look forward to connecting with you!

1. Student First Name *This question is required.

2. Student Last Name *This question is required.

3. Student Birthdate *This question is required. Example: MM/DD/YYYY This question requires a valid date format of MM/DD/YYYY.

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4. Student Email Address *This question is required. This question requires a valid email address.

5. Student Cell Phone Number Example: XXXXXXXXXX This question requires a valid number format.

6. Parent/Guardian First Name

7. Parent/Guardian Last Name

8. Mailing Address *This question is required.

9. City *This question is required.

10. State *This question is required.

11. Zip Code *This question is required. Example: XXXXX This question requires a valid number format.

12. Parent/Guardian Email Address This question requires a valid email address.

13. Parent/Guardian Cell Phone Number Example: XXXXXXXXXX This question requires a valid number format.

14. Additional Parent/Guardian First Name

15. Additional Parent/Guardian Last Name

16. Additional Parent/Guardian Email Address This question requires a valid email address.

17. Would you like to add the contact information for another student? *This question is required.