Artists Creating Together Student Enrollment Form

1
Artists Creating Together 1140 Monroe Ave NW Suite 4101 Grand Rapids, MI 49503 616-885-5866 p 616-885-5867 f
www.artistscreatingtogether.org


You are only required to complete this form once. ACT will file your Student Enrollment Form for office use only.
Todays Date: _______________
Student Information
Student Name:
Street:
City:
State:
Zip code:
Date of Birth:
Age:
Gender:
Phone:
Email Address:
Been to ACT before?

Parent/Guardian Information
Name:
Street:
City:
State:
Zip code:
Phone:
Email address:
Relationship:

Emergency Contact
Name:
Phone:
Relationship:

How did you hear about ACT?
TV/Radio Friend/Family
Newspaper Poster/Brochure/Flyer
Telephone Book Special Event
Website Other Student

Artists Creating Together Student Enrollment Form
2
Artists Creating Together 1140 Monroe Ave NW Suite 4101 Grand Rapids, MI 49503 616-885-5866 p 616-885-5867 f
www.artistscreatingtogether.org

Employer Church
Library Other:

ACT collects student demographic information for funding and grant purposes. This information will be kept confidential.
Family/Education
Number of people in your household:
Estimated Household Annual Income:

Highest Level of School Completed:
No Schooling Certificate of Completion
Grade 1-5 GED
Grade 6-8 Some College
Grade 9-12 College Degree
High School Diploma Other:

Employment Status:
Employed (full-time) Unemployed and looking for a job
Employed (part-time) Not in the labor force at this time

Demographic Information
Hispanic/Latino? Yes? No?

Black/African American Native Hawaiian or other Pacific Islander
Caucasian Asian
American Indian and Alaska Native 2 or more races

Disability (please check all that apply)
Autism Spectrum
Disorder
Deaf/Hearing
Impairment
Physical Impairment Speech/Language
Impairment
Blind/Visual
Impairment
Emotional
Impairment
Severe Multiple
Impairment
Traumatic Brain
Injury
Cognitive
Impairment
Other Health
Impairment
Specific Learning
Disability
Other:


Artists Creating Together Student Enrollment Form
3
Artists Creating Together 1140 Monroe Ave NW Suite 4101 Grand Rapids, MI 49503 616-885-5866 p 616-885-5867 f
www.artistscreatingtogether.org

Accommodations necessary:



Any other physical or mental health concerns that you would like to share?

Allergies (please list):

What is your current form of transportation?

Do you receive public assistance (food stamps, WIC, Medicaid, Medicare, SSI)? Yes No

Have you ever been convicted of a felony/violent or sexual offence? Yes No

Are you currently on parole or probation? Yes No
If yes, we need a signed release including P.O.s name and contact information.




Photo/Video Release
Artists Creating Together (ACT) has my permission to publish my likeness and/or my artwork in any of
their own print, video, internet publication or social media application. It may also be used in media
from a partner or community collaborator that promotes the work of ACT, with ACT permission. I
understand that I may or may not be identified specifically by name. This authorization will remain in my
file and will serve as ongoing authorization for the agency to obtain photos/videos at any time during
my affiliation with ACT.
Signature: __________________________________________________________________________