Emergency Contact
Valid phone AND email contact information for at least one emergency contact is required. Parent or guardian is strongly preferred. It is important that we have at least one adult emergency contact for all participants.

*Parent/Guardian First Name:  
*Parent/Guardian Last Name:  
*Parent/Guardian Phone:            
*Parent/Guardian Email:            
Parent/Guardian Relationship: 
Parent/Guardian Employer:       

Emergency Contact 2 (Optional)
Parent/Guardian 2 First Name:  
Parent/Guardian 2 Last Name:  
Parent/Guardian 2 Phone:          
Parent/Guardian 2 Email:            
Parent/Guardian 2 Relationship:
Parent/Guardian 2 Employer:     


Demographics
The following questions are optional, but really helpful to us. Why do we ask? Demographic information reporting is required by some grant funders, so it helps us create reports. We respect your privacy and will never share your personal information without your permission.

Gender (Check as many as apply):
   --Hold Ctrl to Select Multiple-- Man/Boy Non-binary/genderqueer/agender Non-conforming Transgender Woman/Girl Other

Ethnicity (these are not our definitions, they are defined by grant funders. Please select whatever answer seems best to you):
--Hold Ctrl to Select Multiple-- Asian Black or African American Hispanic or Latinx Indigenous/ Native American/ First Nation Middle Eastern Multiracial/ Multi-ethnic Native Hawaiian or Other Pacific Islander Race/ethnicity unknown White or Caucasian Other - Please Specify
Specify Other Ethnicity:  

Family Income Range:   --None-- $0 - $24,999 $25,000 - $45,000 $45,000 - $55,000 $55,000 - $75,000 More than $75,000 Unsure

Family qualified for MI Bridge benefits?   --None-- Yes No

Eligible for MI Child Health Insurance?   --None-- Yes No