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Parent/Guardian First Name *

Parent/Guardian Last Name *

Parent/Guardian Email Address *

Parent/Guardian Phone number (Number) *

Student Name(s) - Please list all students who live in your household *

Which schools does/do your child(ren) attend? *

Lower Elementary (Kindergarten, 1st, 2nd)
Upper Elementary (3rd, 4th, 5th)
Upper Elementary (6th)
Middle School (7th, 8th)
High School (9th, 10th, 11th, 12th)

Who is your power provider? *

How long have you been without power? *

How long have you been without water? *

Do you currently have road access? *