Project H.O.P.E Interest Form – Changing Lives Coalition, Inc

Parent or Guardian's Name *

First

Last

Child's Name *

First

Last

Child's Age *

Grade in School *

4th-7th graders accepted into the program

Which School Does Your Child Attend? *

Parent or Guardian Email *

Parent or Guardian Phone Number *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Which days will your child attend school? Mondays & Tuesdays? Thursdays & Fridays? *

Why do you feel your child should attend the program? *