Pathway Scholars Program (PSP)
Student Intake & Family Information Form
Student Information
Student Full Name
Preferred Name / Nickname
Date of Birth
Grade
School
Languages Spoken at Home
School-Based Services
None
ELL
SPED
504
Title I
Other
Family / Caregiver Information
Primary Contact Name
Relationship to Student
Phone Number
Email
Secondary Emergency Contact
Academic Interests & Needs
Strengths as a Learner
Areas Needing Support (Math)
Areas Needing Support (Reading)
Hobbies / Interests
Logistics & Permissions
I understand the schedule (Mon–Thu, 5–7 PM)
Permission for nut-free snack
Permission for internal documentation photos
Permission to communicate with teacher(s)
Additional Information
Submit