Student's Name
Legal Last First Middle |
| Gender Male Female |
| Date of Birth (mm/dd/yyyy) SS# |
| Race Enrollment Date |
| Home Address Apt. # |
| City State Zip |
| Home Phone Email |
| |
Mother/Legal Guardian
Name Date of Birth (required by state law) |
| Work Phone Home Phone
|
| Cell Phone Email
|
| |
Father/Legal Guardian
Name Date of Birth (required by state law) |
| Work Phone Home Phone
|
| Cell Phone Email
|
| |
| Student lives with: Mother Father Mother/Father Other
|
| If other, please specify: |
| |
Grade Student applying for:
K 1st 2nd 3rd 4th 5th |
List any special needs of student:
|
How did you hear about the Academy? (list referral name, if applicable)
|
| Primary Language spoken:
|
| |
| |
