Project RESPECT Interest Form

Student Information
Name:*
First Last
Age*
Mobile Phone*
High School*
Current Grade Level*
Personal Email Address*
School Email Address
Address*
Street Address Address Line 2 City State ZIP Code
County:
- Marion
- Dillon
Preferred Method of Contact?
- Select All
- Phone
- Email
Do we have permission to send txt message?
- Yes
- No
Availability to Participate in Virtual Classes*
(Check all that apply):
- Monday Afternoon (4pm- 5pm)
- Monday Evening (5:15pm – 6:15pm)
- Tuesday Afternoon (4:30pm – 5:30pm)
- Tuesday Evening (5:15pm – 6:15pm)
- Wednesday Afternoon (4:30pm – 5:30pm)
- Wednesday Evening (5:15pm – 6:15pm)
- Thursday Afternoon (4:30pm – 5:30pm)
- Thursday Evening (5:15pm – 6:15pm)
How did you hear about us?*
- Arica Nelson
- K'Neisha Williamson
- Cynthia Thomas
- Jessica Fore
- PDHS Website
- Facebook
- Instagram
- Recruiting Event
- Community Event
- High School
- Word of mouth
Parent/Guardian Information
Name*
First Last
Email Address*
Home #*
Mobile #*
Best Time To Contact*
(check all that apply)
- Morning (9am - 12 noon)
- Afternoon (1pm - 4pm)
- Evening (5pm - 8pm)
CAPTCHA

Student Information