Application

Student Information

First Name

Middle Name

Last Name

Grade

Address

City

State

Zip

Home Phone

Place of Birth

Student Resides With

Date of Birth MM/DD/YYYY

Age

Gender (required) Male Female

Ethnic Background

Parent Information

Father's Name

Father's Workplace

Father's Work Phone

Mother's Name

Mother's Workplace

Mother's Work Phone

Legal Guardian Information

Legal Guardian Name

Legal Guardian Workplace

Legal Guardian Work Phone

Emergency Contact Information

Emergency Contact Name

Relationship to Student

Phone Number

Medical Issues

Are there any medical concerns we need to know about? (required) Yes No

If Yes, please explain

Last School Attended

What was the last school attended?

Complete School Name

School Address

School City

School State

School Zip

Are you an out of district student? (required) Yes No

If yes, What district do you reside in?

I have received a copy of the student handbook? (required) Yes No

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What color is the red house?