Name: ________________________________________ Birth Date: _______________________ Address: ______________________________________ Town/City: ________________________ State/Providence: _______________________________ Zip Code: _______________________ Telephone number or TTY: ( ) _______ - _________ Male or Female: (circle one) Webpage: ______________________________________ Email: __________________________ School Name: _________________________________ Grade: __________________________ Address: _______________________________________ Town/City: _______________________ State/Providence: _________________________________ Zip Code: _______________________ Teacher/Professor Name: __________________________ Email: _________________________ Department: ____________________________________ Phone: ________________________ Tell us a little about you! Do you have a challenge or a chronic illness? _____ if yes please explain___________________ ________________________________________________________________________________ Languages you speak or write? ______________________________________________________ School Activities you are involved with? ________________________________________________ Community Volunteering? __________________________________________________________ Hobbies and Interests _____________________________________________________________ Siblings and ages _________________________________________________________________ Do you have Pets? ________________________________________________________________ Favorite food __________________________________ Favorite Color ______________________ Favorite Book ____________________________ Favorite Movie ___________________________ Favorite Music _________________________ Favorite Music Artist ________________________ Favorite Actor/Actress ______________________________________________________________ What computer skills do you have? ___________________________________________________ _________________________________________________________________________________ Student Signature Date ________________________________________________________________________________ Parent/Guardian Signature (students under 18 must have permission to participate) Date |
The Kids' Hospital Network Student Committee Please Print this form out and snail mail or fax it to us Please Clearly Print the Information |
Name: ________________________________________ Birth Date: _______________________ Address: ______________________________________ Town/City: ________________________ State/Providence: _______________________________ Zip Code: _______________________ Telephone number or TTY: ( ) _______ - _________ Male or Female: (circle one) Webpage: ______________________________________ Email: __________________________ School Name: _________________________________ Grade: __________________________ Address: _______________________________________ Town/City: _______________________ State/Providence: _________________________________ Zip Code: _______________________ Teacher/Professor Name: __________________________ Email: _________________________ Department: ____________________________________ Phone: ________________________ Tell us a little about you! Do you have a challenge or a chronic illness? _____ if yes please explain___________________ ________________________________________________________________________________ Languages you speak or write? ______________________________________________________ School Activities you are involved with? ________________________________________________ Community Volunteering? __________________________________________________________ Hobbies and Interests _____________________________________________________________ Siblings and ages _________________________________________________________________ Do you have Pets? ________________________________________________________________ Favorite food __________________________________ Favorite Color ______________________ Favorite Book ____________________________ Favorite Movie ___________________________ Favorite Music _________________________ Favorite Music Artist ________________________ Favorite Actor/Actress ______________________________________________________________ What computer skills do you have? ___________________________________________________ _________________________________________________________________________________ Student Signature Date ________________________________________________________________________________ Parent/Guardian Signature (students under 18 must have permission to participate) Date |
CHECK ONE ONLINE Student Committee ______ LOCAL Student Committee _______ |
