Family Application

Fill this form if this is the first time you apply. Otherwise call us at 650-725-4450.

Parents/Guardian Information

Parent 1 / Guardian

  

Parent 2 / Guardian
First Name: Required. First Name:
Last Name: Required. Last Name:
E-mail:
Required.
Invalid format.		 E-mail: Invalid format.
Work Phone: Invalid format. Work Phone: Invalid format.
Cell Phone: Invalid format. Cell Phone: Invalid format.
Relationship: Relationship:

Family Information

Home Address: Required.   Emergency Contact:
Required.
  Required. Required.Invalid format. Emergency Phone:
Required.Invalid format.
Home Phone: Required.Invalid format. Relationship
Required.
       
Household Size: EPATT Van: Yes  No 
Income: Authorized to Pickup:
Required.
Children live with: Please select one option.  
Required.
     

Interview

1) Are you related to anyone currently in the EPATT program? If so, who and how?

2) How did you hear about the program? (Who referred you?)

Children 1 (Click here)

Basic Information

Full Name: Required. Required.   Birthday:
Required.Invalid format.
E-mail: Invalid format. Gender:
Select a Gender.
School:
Please select a School. 		Ethnicity:
Please select an Ethnicity.
Grade:
Please select a Grade. For the Academic Year 2011-2012. 		     

Medical Information

Medical Problems:   Physician:
  Hospital:
Medications: Insurance:
  Policy #:

Additional Information

Children 2 (Click here)

Basic Information

Full Name:   Birthday: Invalid format.
E-mail: Invalid format. Gender: M  F 
School: Ethnicity:
Grade:  For the Academic Year 2011-2012.      

Medical Information

Medical Problems:   Physician:
  Hospital:
Medications: Insurance:
  Policy #:

Additional Information

Children 3 (Click here)

Basic Information

Full Name:   Birthday: Invalid format.
E-mail: Invalid format. Gender: M  F 
School: Ethnicity:
Grade:  For the Academic Year 2011-2012.      

Medical Information

Medical Problems:   Physician:
  Hospital:
Medications: Insurance:
  Policy #:

Additional Information

I give permission for my child/children to participate in the EPATT program and in all EPATT activities. I absolve EPATT & Stanford University, employees, volunteers and officers from such liability that may arise as a result of participation. I give my consent for photographs or other media in which my child/children may appear to be used in any way they may care to use them. I have read, understand and agree with this statement:

Signature: Required. Date: Required.Invalid format.