Student Information

Student First Name *

Student Last Name *

Date of birth *

Grade To Be Enrolled *

CHOOSE ENROLLMENT

MONDAY-FRIDAY

3 DAYS/2 DAYS ASYNCHRONOUS

Gender *

Student Full Address *

City *

State *

Country *

Postal code *

Has this student been previously applied to or attended this school?

Yes

No

Previous School Name

Previous School State

Dates Enrolled (____ to ___)

Does your child have an IEP or 504 plan?

Yes

No

Is there any other information that I need to know to help better connect and guide your child?

What are your child’s strengths?

What are areas of difficulty for your child?

What are your hopes for your child this school year?

Parent/Guardian Information

Parent/Guardian Name 1

Parent/Guardian Name 2

Are both parent/legal guardian’s address the same as student?

Yes

No

If 'no' above, please provide address

Phone *

Pickup List Information

Pickup Person 1

Pickup Person 1 Phone Number

Pickup Person 2

Pickup Person 2 Phone Number

Pickup Person 3

Pickup Person 3 Phone Number

List anyone NOT allowed to pickup your child?

Emergency Contact

Emergency Contact Name

Emergency Contact Phone Number

Emergency Contact Relationship to Child

Medical Information

Primary Doctor's Name

Primary Doctor's Phone Number

Primary Doctor's Address

Insurance Provider

Preferred Hospital

Please list any health or medical concerns including current medications and/or allergies

Enrollment Documents, Fees

and Signatures

Upload the following documents below: (1) Health Immunizations, (2) Report from previous school, (3) IEP (if applicable)

Upload documents here

Tuition Payment *

Enrollment and Testing Fee (non-refundable)

$100

Signature

Clear

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