Goodwill Community School Registration - Goodwill Industries of Northwest North Carolina, Inc.

Student Name*

First Middle Last

Student Gender*

Male
Female

Student Race*

White
Black
Hispanic
Other

Student Age*

Student Address*

Street Address Address Line 2 City 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 Number

Alternate Authorized Pickup - Relationship to Student

How did you hear about the Goodwill Community School? (choose one)*

Goodwill Employee
Community Partner
Teacher/Counselor

Is the student's parent/guardian an employee of Goodwill?*

Yes
No

Name of Parent Employed by Goodwill*

Rules of Conduct

The 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