Student Application

About Student

Application Date(Required)

MM slash DD slash YYYY

Student Gender(Required)

Male

Female

Grade Entering(Required)

Select Grade

Student Name(Required)

First Last

Date of Birth(Required)

MM slash DD slash YYYY

Student Address(Required)

Street Address Address Line 2 City ZIP Code

Race/Ethnicity

Black/African-American

Hispanic

Caucasian

Asian

Native American

SSN

Hospital Preference

Insurance Carrier

Insurance Group ID

Policy 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

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

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

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 Information

We would love to chat with you. How can we get in touch?

Last Name(Required)

Middle Initial

First Name(Required)

Home Address(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Occupation(Required)

Employed by:(Required)

Work Address

Work Hours

Primary 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):

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 sign

Date(Required)

MM slash DD slash YYYY

Consent(Required)

I agree to the privacy policy.