Goodwill Community School Registration Thank you for your interest in Goodwill Community Schools, a program of Youth Connections. Please complete the form below and someone will contact you shortly with more information. Student Name* First Middle Last Student Gender*MaleFemaleStudent Race*WhiteBlackHispanicOtherStudent Age*Student Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent's Preferred Phone Number*Alternative Phone Number (optional)School Name*Current Grade Level*Emergency Contact* First Last Emergency Contact Preferred Phone Number*Emergency Contact Alternate Phone Number (optional)Emergency Contact Relationship to Student*Authorized Pickup - Name* First Last Authorized Pickup - Phone Number*Authorized Pickup - Relationship to Student*Authorized Pickup - Code Word for Pickup*Alternate Authorized Pickup - Name First Last Alternate Authorized Pickup Person Phone NumberAlternate Authorized Pickup - Relationship to StudentHow did you hear about the Goodwill Community School? (choose one)*Goodwill EmployeeCommunity PartnerTeacher/CounselorIs the student's parent/guardian an employee of Goodwill?*YesNoName of Parent Employed by Goodwill*Rules of ConductThe following activities are not allowed while attending the Goodwill Community School: visiting social media, video, music, or message sites (e.g. Facebook, Instagram, Twitter, Pandora, TikTok, YouTube etc.); violating any state, federal or local law; use of threatening, offensive or abusive language; harassment of employees or other youth; misuse or defacement of property.Electronic Signature*By checking this box and typing my name, I am agreeing to comply with the rules set for the Goodwill Community School and understand that failure to do so will result in restriction of services and/or removal from the facility. I comply with the Rules of Conduct for the Goodwill Community School.Student Name (or Parent/Guardian Name if Student is under the Age of 18)* First Last Student or Parent