First Name*
 
Last Name*
 
Address*
 
City*
 
State*
 
Zip Code*
 

Please provide at least two phone numbers (in case of an emergency or if we need to reach you).
Indicate whose phone after the number. Examples: (my cell), (mom's cell), (home phone), (grandparents)

Phone number 1
Phone number 2
Phone number 3

Grade* (in Fall 2016)
 
School* (in Fall 2016)
 

Have you been a Kid Power volunteer before?*
 
What years?

    * required