Full Time SchoolApply Now Home / Full Time School Apply Now STUDENT ENROLLMENT FORMAcademic School Year *Grade *Last School Attended *Name of School *Address *Telephone *STUDENT INFORMATIONFirst Name *Middle NameLast NameDate of Birth *City of Birth *Gender *Street Address *Apartment, suite, etc *City *State/Province *ZIP / Postal Code *Home Phone Number *Languages Spoken at Home Other Than English *Does your child currently receive any special education services? *YesNoPlease provide the most recent IEP (Individualized Education Plan) *Choose FileNo file chosenDelete uploaded filePARENT INFORMATIONFather’s Full Name *Mother’s Full Name *Home Address (If different than students) *Home Address (If different than students) *Father’s Cell Phone Number *Mother’s Cell Phone Number *Father’s E-Mail Address *Mother’s E-Mail Address *Siblings (Please list all siblings)NameGradeDate of BirthNameGradeDate of BirthNameGradeDate of BirthNameGradeDate of BirthPARENT OCCUPATIONFather *Mother *Student Living With: *FatherMotherStepfatherStepmotherGrand ParentsAre there any court orders in place regarding your child's educational rights? *YesNoPick-Up:Please list names of anyone that will be picking up your child on a regular basisName *Relationship *NameRelationshipNameRelationshipCustody:If there is a custody arrangement pertaining to your child, please make us aware of anyone that should not be allowed to pick up or acquire information about your child. *Legal documentation is required.Please explain *Emergency ContactsName *Phone Number *Name *Phone Number *NamePhone NumberNamePhone NumberMedical InformationDISABILITIES: Please list any physical limitations or disabilities your child may have and what restrictions they may cause. *ALLERGIES: Please list ALL allergies and medications needed. If your child has a severe food allergy please let us know immediately so we may plan snacks accordingly, as well as post signs in the classroom. We will also have to schedule a meeting with the child’s parents/caregiver to discuss emergency procedures before the child is left in our care. *Does your child currently receive any special education services? *Does your child have any medical conditions, learning differences, behavioral needs (such as ADHD, ADD, autism, etc.), or other special needs that may affect their learning, behavior, or daily routine at school? *If you have a doctor’s report or educational assessment, please attach it with the registration form. *Drag and Drop (or) Choose FilesChild's Doctor InformationDoctor Name *Doctor Phone Number *Street Address *City *State/Province *ZIP / Postal Code *Insurance InformationPolicyholder *Group/Member # *I hereby certify and solemnly affirm under penalty of perjury that all information provided in this application is true, accurate, and complete to the best of my knowledge.I understand and agree that any misrepresentation, omission, or falsification of information may result in the immediate disqualification of this application. Furthermore, I acknowledge and accept that the enrollment application, and any admission granted pursuant thereto, is subject to revocation at any time at the sole discretion of the institution. Submit ApplicationPlease do not fill in this field.
