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QCC - STEP APPLICATION 2023-2024

PARENT/GUARDIAN INFORMATION

Parent/Guardian Name(s):

Address

Address Line 1

Address Line 2

City

State

ZIP Code

Best Phone #:

Parent/Family Email:

EMERGENCY CONTACT

Name of a relative not residing with you:

Phone (H):

Phone (M):

Phone (W):

Which is the best contact number on a Saturday?

Relationship to STEP student:

Name of 2nd Contact:

Phone (H):

Phone (M):

Phone (W):

Which is the best contact number on a Saturday?

Relationship to STEP student:

STUDENT PHOTO RELEASE

I give permission/I do not give permission to the QCC STEP Program to use photographs (whether still or motion) for publicity regarding this program.*

Type full name of student

Student’s Signature*

[clear]

Use your mouse or finger to draw your signature above

Parent/Guardian Signature