This field is hidden when viewing the formNext Steps: Sync an Email Add-OnTo get the most out of your form, we suggest that you sync this form with an email add-on. To learn more about your email add-on options, visit the following page (https://www.gravityforms.com/the-8-best-email-plugins-for-wordpress-in-2020/). Important: Delete this tip before you publish the form.About YouDate(Required) MM slash DD slash YYYY Student Gender(Required) Male Female Grade Entering(Required)Your Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Your Address(Required) Street Address Address Line 2 City ZIP Code Race/Ethnicity Black/African-American Hispanic Caucasian Asian Native American SSN(Required)Hospital PreferenceInsurance CarrierInsurance Group IDPolicy ID #Existing medical conditions, medications and/or special attention your child may require:(Required)Allergies (if applicable please explain the reaction type as well):Does your child have an IEP, 504 Plan, or identified learning disability?(Required) Yes No If yes, please specify and attach any necessary documentation.Max. file size: 2 GB.Has your child ever been suspended or expelled from school?(Required) Yes No If yes, please provide dates and reason for disciplinary action.Max. file size: 2 GB.Has your child ever been retained or repeated a grade?(Required) Yes No If yes, what grade and year?Additional Comments and Information: Is there any other information that would be helpful to our management and teaching staff?Parent InformationWe would love to chat with you. How can we get in touch?Last Name(Required)Middle Initial(Required)First Name(Required)Home Address(Required)Date of Birth(Required) MM slash DD slash YYYY Occupation(Required)Employed by:(Required)Work AddressWork HoursPrimary Phone Number(Required)Primary Email(Required)Custodial Parent (if married mark for both parents) Time-sharing (please indicate which days student resides with Mother/ Guardian 1):(Required) Mon Tues Wed Thur Fri Martial Status(Required) Married Single Divorced Separated Widowed Highest Level of Education GED High School Some College Bachelors Masters or Higher Attest(Required) By signing this form, I attest that I am the legal guardian with full authority to make educational decisions for the student listed on this form. I further agree to provide any and all supporting documentation of this. I attest that all information listed on the document is true and correct.Consent(Required) By accepting this Agreement, you consent and agree that your use of a key pad, mouse or other device to select an item, button, icon or similar act or action while using any electronic service we offer or in accessing or making any transactions regarding any documents and disclosures constitutes your signature as if actually signed by you in writing (electronic signature)Parent Guardian Signature(Required)Type full name to signDate(Required) MM slash DD slash YYYY Δ
