CTE Youth Traning Center of Baton Rouge Please take your time and complete this form. Step 1 of 5 20% Student InformationHow many students*01234Student 1Name* First Last Gender* Male Female Date of birth*MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920School* Grade (Enter the child's next year grade or promotion grade)*9th10th11th12thFreshman (college)Sophomore (college)Junior (college)Senior (college)If the individual enrolling is not in school, please select last grade completed.Year*201820192020202120222023Enter current year.Student 2Name* First Last Gender* Male Female Date of birth*MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920School* Grade (Enter the child's next year grade or promotion grade)*9th10th11th12thFreshman (college)Sophomore (college)Junior (college)Senior (college)If the individual enrolling is not in school, please select last grade completed.Year*201820192020202120222023Enter current year.Student 3Name* First Last Gender* Male Female Date of birth*MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920School* Grade (Enter the child's next year grade or promotion grade)*9th10th11th12thFreshman (college)Sophomore (college)Junior (college)Senior (college)If the individual enrolling is not in school, please select last grade completed.Year*201820192020202120222023Enter current year. Parent/Guardian informationParent/Guardian Name* First Last Phone*Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Alt PhoneEmployer Work Phone Emergency Contact InformationEnter the names of those authrozied to pick up your child.Contact 1 Name First Last Contact 1 PhoneContact 1 Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact 2 Name First Last Contact 2 PhoneContact 2 Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Trade of Choice*ElectricalPipe FittingWelding Permission & ReleasesI give AKCCL's authorized personnel permission to transport my child, in the event that I or the contact(s) list above is unavailable or unable to be contacted, and my child requires transportation. I give my child permission to participate in all physical education activities. I consent to the use of any photograph of my child/dependent/self, and/or any copies of this photograph in any editorial and/or promotional material produced and/or published. **In case of an accident, serious injury, or illness, the program will contact you. In the event that we cannot reach you, your signature below authorizes officials of the AKCCL to take whatever action is deemed necessary, in their judgment, for the health and safety or your child. It is given to provide consent for medical care.** Permission Granted* Yes Health InfomationMedical ConsiderationsPlease indicate if your child has any specific medical considerations on the lines provided. ( Allergies, food, medication, etc. ) Eligibility Requirement (Check all that apply)* Financial Hardship/Low Income Failing/Low Performing Student Poor School Attendance Muliple Behavior Occurences/ADHD/ODD diagnosis ACT score is a 16 or below Monthly Household Income* Number of Household Members* Does the participant recieve/benefit from any of the following? (Please check all that apply.)* Medicaid SNAP Benefits (Food Stamps) Government Financial Subsidies N/A Files to Upload (Student Medicaid Card, Birth Certificate, and ID or Drivers License* Drop files here or Select files Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 1 GB. Provide documentation to support your request.You may type or provide your explanation below.Registration CostDeposit/Registration is fifty dollars ($50.00) per student. This registration secures your child's slot.Authorization* Yes Checking this box confirms authorization of payment and indicates that I have provided the information above to the best of my ability.