RAMPKids Information Form

Student's Name

First Name

Last Name

Student's Email Address

Student's Phone Number

(###)

###

####

I can receive text messages

Yes

No

How did you hear about this program

Parent's Name

First Name

Last Name

Parent's Email

2nd Parent's Email

Mother's Phone Number

(###)

###

####

Father's Phone Number

(###)

###

####

Student's age

Grade

School

Date

MM

DD

YYYY