Student Information Form

First Name *

(if you go by a nickname, add it in parenthesis)

Last Name *

Birth Date *

// (mm/dd/yyyy)

PHAME can add up to three emails to PHAME's informational distribution lists to receive updates on schedules, events, school closures, etc. Please list up to three emails here. Only these three emails will receive these updates.

Primary Email *

Additional Email 1

Additional Email 2

Please tell us who the emails belong to.

Please list up to three phone numbers for the student and/or support people. Please list the name of the person whose phone this is after each phone number.

Primary phone *

Additional phone 1

Additional phone 2

Please list the student's home address.

Address *

Apartment Number

City *

State/Province *

Zip *

If you live with family, please list their full names. This helps us address occasional newsletters correctly.

PHAME sends invoices by email. Please list the email that should receive your invoices. *

Some of our students have a support person (often a parent or paid caregiver) to help them fill out forms, register for classes, make payments, correspond with PHAME, etc. If you have a suppport person, please list their name and their relationship to you. Include their phone and email in the phone and email sections above.

Support person name/relationship

If we need to get in touch, who should we contact? *

Student is the contact for calls and e-mails
Student is the contact for calls and e-mails, CC support person
Support person is the contact for calls and e-mails
Support person is the contact for calls and e-mails, CC student

If you use Trimet LIFT and would like PHAME staff to be able to help you keep track of your pick up time while on campus, please enter your TriMet Customer ID number here. PHAME will keep this information private.

TriMet Customer ID Number

Check this box if you do not have regular access to email and need a phone call if PHAME must close campus unexpectedly

Requires a phone call for school closures

Demographic Information

What is your gender? *

What are your gender pronouns? *

She/Her/Hers
He/Him/His
They/Them/Theirs
Other
No response/ Decline to state

Do you identify as any of the following? *

Nonbinary
Trans
Lesbian, Gay, or Bisexual
Other LGBTQ+
Decline to state
None of the above

What languages do you speak at home? *

English
Spanish
American Sign Language
Other
No response/ Decline to state

What is your race? *

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
No response/Decline to state

Are you of Hispanic, Latinx, or Spanish origin? *

No, NOT of Hispanic or Latinx or Spanish Origin
Yes, of Hispanic or Latinx or Spanish Origin
No response/ Decline to state

What is your annual income level? (please list the student's income only, not household income) *

Less than $11,880
$11,880 - $20,000
$20,000 - $50,000
More than $50,000
No response/ Decline to state

Health, Accommodation & Emergency Information

If you wish to tell us what kind of disability you experience, or if you have information about your health, medication, preferred hospital, physician, etc that you would like us to be aware of, please share it here. We do not share this information with our teaching artists.

Disability/ Medical information

Please check any options that apply to you

Wheelchair user
Uncomfortable with stairs sometimes or always
Non-speaking
History of seizures/epilepsy

Have you ever had a seizure? Note that if a student has a seizure at PHAME, we will administer basic first aid and will call 911.

Seizure response

Check any dietary restrictions you would like us to be aware of

Vegetarian
Vegan
Gluten-Free
Dairy-Free
Kosher-Stye
Other
None

Do you have any allergies?

Do you need any accommodations or modifications durring PHAME programming, or is there anything you would like us to know that will help you participate fully? PHAME will share this information with our teaching artists.

Accommodation and modification information

What is your reading level? *

Beginner (reads very little or not at all)
Intermediate (comfortably reads simple sentences)
Advanced (a confident reader)

Are you accustomed to and comfortable with leaving campus on your own? (For reference only. PHAME is an open campus and we don’t require students to sign in and out of campus.)

Please choose one *

Please list two emergency contacts, their relationship to you, and their phone numbers. *

We're so glad you found us!

How did you hear about PHAME? *

A Provider, Brokerage, or PSW
A School/Transition Program
A Case Manager
A Parent/Guardian/Family member
A PHAME Performance
A PHAME Student or PHAME family
A PHAME Board or Staff Member
The PHAME Website or Online Search
Social Media
A Magazine/Newspaper
I am a Returning PHAME student
Other

Timeout Warning

Student Information Form

Demographic Information

Health, Accommodation & Emergency Information

We're so glad you found us!