First Name:                    Last Name: 

Street Address:           

City:                   State:          Zip:           

Home Phone:    

Gender:    Male   Female

Ethnicity:            American Indian    Asian    Black    Hispanic    White

(NOTE:  classes are balanced by race and gender)

Grade Entering in Fall 2008:            5     6     7     8    9     10

School Attending in Fall 2008:           

Please select the grade-appropriate morning program:            Please select one... 5 - Our Hartford Roots (A) 6 - Our Hartford Roots (B) 7 - Roots II 8 - Environment and Technology 9 - Community Action Program 10 - Strategies for Success

Students will select their afternoon activities (such as basketball, drill team, etc.) on the first day of the program.

TRANSPORTATION:

A minimum of 10 students is required from a town or contiguous towns for each bus.  CREC strives to provide transportation for all EQUAL participants.  All bus stops will be located at neighborhood schools for convenience and safety.

For transportation purposes please name the elementary, middle or high school closest to your home:
Choice 1:            Choice 2:      Choice 3: 

1st Parent/Guardian Info:

Salutation:   Please select one... Ms. Mrs. Mr. Mr. and Mrs. Dr.     First Name:           Last Name:  

Street Address:

City:      State:      Zip:     

Work Phone:      Cell Phone: 

2nd Parent/Guardian Info:

Salutation:   Please select one... Ms. Mrs. Mr. Mr. and Mrs. Dr.     First Name:          Last Name:  

Street Address:

City:      State:      Zip:     

Work Phone:      Cell Phone: 

Emergency Contact Information:

Name:      Emergency Phone: 

Would you like to receive financial aid forms?            Yes    No

A limited number of scholarships are available based on financial need.  All information you provide on the financial aid forms will remain confidential.  Proof of earnings is required.