Pathway Interest Form 2017-2018

Student First Name

Student Last Name

Birthdate

School (in Fall 2017)

Grade (in Fall 2017)

Time Student Can Arrive to MetroSquash on Weekdays:

Please list any extracurricular activities and tentative schedules

Please write any accommodations we should take into consideration to better support your student.

Examples: My student has asthma and carries an inhaler. My student has a history of anxiety.

Student Demographics

Ethnicity

Gender

Free/Reduced Lunch

Mailing Address

City

State

Postal Code

Family Financial Statement

MetroSquash receives funding from Chicago’s Department of Family and Support Services which is dedicated to supporting services that enhance the lives of Chicago residents, particularly families in need. While we understand that financial information is sensitive, MetroSquash is asking each family to describe their financial situation so we can continue serving Chicago families in need.

In the space below, please explain the status of your family’s finances. Information should include: yearly income and number of individuals in your household but can also include a description about parenting status, free/reduced lunch, financial government assistance, debt, or any other extenuating circumstances. Your response will be kept confidential and not shared with anyone outside of the MetroSquash staff.

Household Income Per Year

Number of People in Household

Additional Information

Guardian Information

Guardian First Name

Guardian Last Name

Relationship to Student

Phone Number

Okay to Text?

Highest Level of Education Completed

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