ENROLLMENT FORM

Student Information

Student Name

Grade at school for upcoming year

City and State of Birth

Date of Birth

New or returning student

Male or Female

Household Information

Mailing Address

Primary Phone Number

Primary Email for Family

What School District do you reside in?

Do we have permission to include you in the school directory?

Parent 1

Name

Cell Phone

Employer

Relation to student

Work Phone

Occupation

Is this parent the one responsible for overseeing the financial responsibility of tuition and overall correspondence with the school?

YesNo

Parent 2

Name

Cell Phone

Employer

Relation to student

Work Phone

Occupation

Is this parent the one responsible for overseeing the financial responsibility of tuition and overall correspondence with the school?

YesNo

Emergency contact name

Emergency Contact Name

Relationship to Student

Phone

Health Information

Allergies

Medical conditions

Medications

Dentist Name and Phone

Physician name and phone

Supplemental Question

Please describe the student’s educational history