Charting Careers Enrollment Form

Thank you for your interest in Charting Careers! This is our participant enrollment form for 1) parents/caregivers enrolling their children with Charting Careers education and mentoring programs and 2) parents/caregivers who are enrolling themselves to receive family and community partnership support. If you are enrolling more than one person, you will need to complete this form separately for each person.

If you need help completing the form, please contact a Charting Careers staff member.

Are you completing this form to enroll a student or to enroll yourself as a parent/caregiver? *This question is required.

Please answer the following questions on behalf of your student.

Participant's Basic Information

First Name (Legal Name) *This question is required.

Last Name (Legal Name) *This question is required.

Date of Birth *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

Street Address *This question is required.

Apt/Suite

City *This question is required.

Zip *This question is required.

Preferred Email *This question is required. This question requires a valid email address.

Preferred Phone Number *This question is required.

Preferred Secondary Phone Number

Emergency Contact Information

First and Last Name *This question is required.

Relationship *This question is required.

Preferred Phone Number *This question is required.

If you said other, please specify. *This question is required.

If you said other, please specify.

Do you speak another language other than English? *This question is required.

What languages are you comfortable speaking? *This question is required.

Arabic
Chinese (Mandarin, Cantonese)
English

French
Korean
Somali

Spanish
Swahili
Tagalog

Vietnamese
Other

If you said other, please specify.

Does your family qualify for free or reduced meals at school? *This question is required.

What type of health insurance do you have? *This question is required.

If you said other, please specify. *This question is required.

Insurance Company (if applicable):

Member ID:

Group #:

Name of Insured:

Neighborhood: Which, if any, of the following neighborhoods does your family live in? *This question is required.

If you said other, please specify. *This question is required.