Richmond Village Beacon

Middle School Registration

fields marked with a * must be filled

Member Information

First name*

M.I.

Last Name*

School

Grade

HO# (if public school student)

Email*

Date of Birth*
Month Date Year

Gender*
 Male Female

Street Address*

City*

Zip Code*

Phone*

Parent/Guardian Information

Relationship

First Name*

Last Name*

Primary Phone*

 Home Cell

Street Address*

City*

Zip*

Work Phone

Email

Second Parent/Guardian Information (optional)

Relationship

First Name

Last Name

Primary Phone

 Home Cell

Street Address

City

Zip

Work Phone

Email

Emergency Contact
(will be contacted if parent/guardian is unavailable)

First Name*

Last Name*

Primary Phone*

 Home Cell

Street Address*

City*

Zip*

Work Phone

The following information is optional and used only for data purposes

Race/Ethnicity
 African-American Chinese Filipino Japanese Samoan Vietnamese Other Asian Caucasian Latino Native American Russian Multiracial Other (please specify)

Home Language
 English Spanish Cantonese Mandarin Korean Vietnamese Japanese Laotian Russian Samoan Other (please specify)

English Fluency
 Fluent Not Fluent Somewhat Fluent

Other Characteristics
 Special Needs Gay/Lesbian Teen Parent TANF Homeless Public Housing Public School Has Foster Care

How did you find out about the Richmond Village Beacon?
 Teacher Friend Family Member Beacon Staff Community Member Announcement Poster Church Other (please specify)

What programs or activities would you like the Beacon to offer in the future?

Medical Information

Allergies

Diseases

Current Medications

Special Needs

Does the youth member have medical insurance? If yes, please identify the insurance carrier and policy number below: