Date of Last Upload:
Friday, December 1, 2023
Student Enrollment Form
New Student Information
Select the Submit Application tab after you have filled in all information including students, primary and secondary family, and emergency/contacts. Use the tab buttons to select the pages to fill in the information.
*
Required fields are bold.
Student's Information
Primary Family Information
Secondary Family Information
Contact Information
Submit Application
Student 1
*
Last Name
*
First Name
Middle Name
Preferred Name
Date of Birth
Suffix
<None>
Sr.
Jr
Title
<None>
Dr.
Miss
Mr.
Mrs.
Ms.
Rev.
Mr
Mrs
Church Affiliation
<None>
Baptist
Church of Christ
Episcopal
Lutheran
Non-Denominational
Presbyterian
Roman Catholic
Gender
<None>
Female
Male
Race
<None>
African American
Asian
Caucasian
Hispanic
Native American
E-Mail
*
Grade Level
<None>
Infant
Toddler
1 Yr Old
2 Yr Old
3 Yr Old
4 Yr Old
K5
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
Grade 8
Grade 9
Grade 10
Grade 11
Grade 12
Ones- Mondays- $120.00
Blood Type
<None>
A+
A-
AB+
AB-
B+
B-
O+
O-
Student 2
*
Last Name
*
First Name
Middle Name
Preferred Name
Date of Birth
Suffix
<None>
Sr.
Jr
Title
<None>
Dr.
Miss
Mr.
Mrs.
Ms.
Rev.
Mr
Mrs
Church Affiliation
<None>
Baptist
Church of Christ
Episcopal
Lutheran
Non-Denominational
Presbyterian
Roman Catholic
Gender
<None>
Female
Male
Race
<None>
African American
Asian
Caucasian
Hispanic
Native American
E-Mail
*
Grade Level
<None>
Infant
Toddler
1 Yr Old
2 Yr Old
3 Yr Old
4 Yr Old
K5
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
Grade 8
Grade 9
Grade 10
Grade 11
Grade 12
Ones- Mondays- $120.00
Blood Type
<None>
A+
A-
AB+
AB-
B+
B-
O+
O-
Student 3
*
Last Name
*
First Name
Middle Name
Preferred Name
Date of Birth
Suffix
<None>
Sr.
Jr
Title
<None>
Dr.
Miss
Mr.
Mrs.
Ms.
Rev.
Mr
Mrs
Church Affiliation
<None>
Baptist
Church of Christ
Episcopal
Lutheran
Non-Denominational
Presbyterian
Roman Catholic
Gender
<None>
Female
Male
Race
<None>
African American
Asian
Caucasian
Hispanic
Native American
E-Mail
*
Grade Level
<None>
Infant
Toddler
1 Yr Old
2 Yr Old
3 Yr Old
4 Yr Old
K5
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
Grade 8
Grade 9
Grade 10
Grade 11
Grade 12
Ones- Mondays- $120.00
Blood Type
<None>
A+
A-
AB+
AB-
B+
B-
O+
O-
Student 4
*
Last Name
*
First Name
Middle Name
Preferred Name
Date of Birth
Suffix
<None>
Sr.
Jr
Title
<None>
Dr.
Miss
Mr.
Mrs.
Ms.
Rev.
Mr
Mrs
Church Affiliation
<None>
Baptist
Church of Christ
Episcopal
Lutheran
Non-Denominational
Presbyterian
Roman Catholic
Gender
<None>
Female
Male
Race
<None>
African American
Asian
Caucasian
Hispanic
Native American
E-Mail
*
Grade Level
<None>
Infant
Toddler
1 Yr Old
2 Yr Old
3 Yr Old
4 Yr Old
K5
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
Grade 8
Grade 9
Grade 10
Grade 11
Grade 12
Ones- Mondays- $120.00
Blood Type
<None>
A+
A-
AB+
AB-
B+
B-
O+
O-
Student 5
*
Last Name
*
First Name
Middle Name
Preferred Name
Date of Birth
Suffix
<None>
Sr.
Jr
Title
<None>
Dr.
Miss
Mr.
Mrs.
Ms.
Rev.
Mr
Mrs
Church Affiliation
<None>
Baptist
Church of Christ
Episcopal
Lutheran
Non-Denominational
Presbyterian
Roman Catholic
Gender
<None>
Female
Male
Race
<None>
African American
Asian
Caucasian
Hispanic
Native American
E-Mail
*
Grade Level
<None>
Infant
Toddler
1 Yr Old
2 Yr Old
3 Yr Old
4 Yr Old
K5
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
Grade 8
Grade 9
Grade 10
Grade 11
Grade 12
Ones- Mondays- $120.00
Blood Type
<None>
A+
A-
AB+
AB-
B+
B-
O+
O-
Primary Family Information
Address Line 1
Address Line 2
City
State
ZIP Code
Home Phone
Home Listed
Cell Phone
Cell Listed
Parent 1 Information
*
Last Name
*
First Name
Middle Name
Preferred Name
Date of Birth
Marital Status
<None>
Divorced
Engaged
Married
Separated
Single
Widow
Widower
Suffix
<None>
Sr.
Jr
Title
<None>
Dr.
Miss
Mr.
Mrs.
Ms.
Rev.
Mr
Mrs
Church Affiliation
<None>
Baptist
Church of Christ
Episcopal
Lutheran
Non-Denominational
Presbyterian
Roman Catholic
Gender
<None>
Female
Male
Race
<None>
African American
Asian
Caucasian
Hispanic
Native American
Home E-Mail
Cell Phone
Cell Listed
Company Name
Business Phone
Extension
Job Title
Is Emergency Contact
Business E-Mail
Is Allowed to Pickup
Parent 2 Information
*
Last Name
*
First Name
Middle Name
Preferred Name
Date of Birth
Marital Status
<None>
Divorced
Engaged
Married
Separated
Single
Widow
Widower
Suffix
<None>
Sr.
Jr
Title
<None>
Dr.
Miss
Mr.
Mrs.
Ms.
Rev.
Mr
Mrs
Church Affiliation
<None>
Baptist
Church of Christ
Episcopal
Lutheran
Non-Denominational
Presbyterian
Roman Catholic
Gender
<None>
Female
Male
Race
<None>
African American
Asian
Caucasian
Hispanic
Native American
Home E-Mail
Cell Phone
Cell Listed
Company Name
Business Phone
Extension
Job Title
Is Emergency Contact
Business E-Mail
Is Allowed to Pickup
Secondary Family Information
Address Line 1
Address Line 2
City
State
ZIP Code
Home Phone
Home Listed
Cell Phone
Cell Listed
Parent 3 Information
*
Last Name
*
First Name
Middle Name
Preferred Name
Date of Birth
Marital Status
<None>
Divorced
Engaged
Married
Separated
Single
Widow
Widower
Suffix
<None>
Sr.
Jr
Title
<None>
Dr.
Miss
Mr.
Mrs.
Ms.
Rev.
Mr
Mrs
Church Affiliation
<None>
Baptist
Church of Christ
Episcopal
Lutheran
Non-Denominational
Presbyterian
Roman Catholic
Gender
<None>
Female
Male
Race
<None>
African American
Asian
Caucasian
Hispanic
Native American
Home E-Mail
Cell Phone
Cell Listed
Company Name
Business Phone
Extension
Job Title
Is Emergency Contact
Business E-Mail
Is Allowed to Pickup
Parent 4 Information
*
Last Name
*
First Name
Middle Name
Preferred Name
Date of Birth
Marital Status
<None>
Divorced
Engaged
Married
Separated
Single
Widow
Widower
Suffix
<None>
Sr.
Jr
Title
<None>
Dr.
Miss
Mr.
Mrs.
Ms.
Rev.
Mr
Mrs
Church Affiliation
<None>
Baptist
Church of Christ
Episcopal
Lutheran
Non-Denominational
Presbyterian
Roman Catholic
Gender
<None>
Female
Male
Race
<None>
African American
Asian
Caucasian
Hispanic
Native American
Home E-Mail
Cell Phone
Cell Listed
Company Name
Business Phone
Extension
Job Title
Is Emergency Contact
Business E-Mail
Is Allowed to Pickup
Contact Information (Other than parents)
Contact 1
*
Last Name
*
First Name
Relation
<None>
Aunt
Friend
Grandparent
Spouse
Brother
Father
Mother
Uncle
Sister
Is Emergency Contact
Home Phone
Is Allowed to Pickup
Business Phone
Pickup License
Cell Phone
Pickup Tag
Pickup Notes
Contact 2
*
Last Name
*
First Name
Relation
<None>
Aunt
Friend
Grandparent
Spouse
Brother
Father
Mother
Uncle
Sister
Is Emergency Contact
Home Phone
Is Allowed to Pickup
Business Phone
Pickup License
Cell Phone
Pickup Tag
Pickup Notes
Contact 3
*
Last Name
*
First Name
Relation
<None>
Aunt
Friend
Grandparent
Spouse
Brother
Father
Mother
Uncle
Sister
Is Emergency Contact
Home Phone
Is Allowed to Pickup
Business Phone
Pickup License
Cell Phone
Pickup Tag
Pickup Notes
Medical Contacts
Physician
Physician Phone Number
Dentist
Dentist Phone Number
Hospital
Hospital Phone Number
Insurance
Insurance Phone Number
Policy Number
Finished
Confirmation E-Mail address:
Please press the save button to submit the new student application.
