Enrollment Form

ENROLLMENT FORM

Please complete the form below. Required fields marked with an asterisk *

Today's Date*

Answer Required

Student's First Name*

Answer Required

Middle Name*

Answer Required

Last Name*

Answer Required

Student's Date of Birth*

Answer Required

Grade Level Requesting*

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Email 1*

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Address

Mailing Address*

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Street Address*

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City

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Zip/Postal*

Answer Required

Mobile Phone*

Number Required

Home Phone*

Number Required

Work Phone*

Number Required

Father's Name*

Answer Required

Father's Occupation and Employed by*

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Mobile Phone*

Number Required

Mother's Name*

Answer Required

Mother's Occupation and Employed by*

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Mobile Phone*

Number Required

Name and Address of former school*

Answer Required

Name and ages of children not of school age (Under the age of five):

Answer Required

Is the Student (or you) Hispanic or Latino?*

Answer Required

No, not Hispanic or Latino

Yes, Hispanic or Latino (A person of Mexican, Puerto Rican, Cuban South or Central American, or other Spanish culture or origin, regarless of race).

What is ithe Student's (or your) race? (Regardless of how you answered the first question, choose one or more).*

Answer Required

American Indian or Alaska Native ( A person having origins in any of the original peoples of North and South America, including Central America, and who maintains tribal affiliation or community attachment).

Asian (A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, Philippine Islands, Thailand and Vietnam).

Black or African American ( A person having origins in any of the black racial groups of Africa).

Native Hawaiian or Other Pacific Islander (A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands).

White (A person having origins in any of the original peoples of Europe, the Idle East, or North Africa).

Did your child receive any special services at the previous school? (Click all that apply)

Answer Required

Special Education

Speech Therapy

Title Reading

Title Math

Adaptive PE

Please list any special medical conditions below:

Answer Required

A COPY OF THE STUDENT'S STATE ISSUED BIRTH CERTIFICATE AND CURRENT IMMUNIZATIONS ARE NEEDED FOR STUDENTS FILES.

Please fix the highlighted areas below before submitting.

Enrollment Form