Date of Last Upload:
Friday, January 17, 2025
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 (mm/dd/yyyy)
Suffix
<None>
Jr
*
Gender
<None>
Female
Male
Race
<None>
African American
Asian
Caucasian
Hispanic
Indian
Native American
Polish
*
Home E-Mail
Student 2
*
Last Name
*
First Name
Middle Name
Preferred Name
*
Date of Birth (mm/dd/yyyy)
Suffix
<None>
Jr
*
Gender
<None>
Female
Male
Race
<None>
African American
Asian
Caucasian
Hispanic
Indian
Native American
Polish
*
Home E-Mail
Student 3
*
Last Name
*
First Name
Middle Name
Preferred Name
*
Date of Birth (mm/dd/yyyy)
Suffix
<None>
Jr
*
Gender
<None>
Female
Male
Race
<None>
African American
Asian
Caucasian
Hispanic
Indian
Native American
Polish
*
Home E-Mail
Student 4
*
Last Name
*
First Name
Middle Name
Preferred Name
*
Date of Birth (mm/dd/yyyy)
Suffix
<None>
Jr
*
Gender
<None>
Female
Male
Race
<None>
African American
Asian
Caucasian
Hispanic
Indian
Native American
Polish
*
Home E-Mail
Student 5
*
Last Name
*
First Name
Middle Name
Preferred Name
*
Date of Birth (mm/dd/yyyy)
Suffix
<None>
Jr
*
Gender
<None>
Female
Male
Race
<None>
African American
Asian
Caucasian
Hispanic
Indian
Native American
Polish
*
Home E-Mail
Primary Family Information
*
Address Line 1
Address Line 2
*
City
*
State
*
ZIP Code
Home Phone
Home Listed
*
Mobile Phone
Mobile 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>
Jr
Title
<None>
Dr.
Miss
Mr.
Mrs.
Ms.
Rev.
Gender
<None>
Female
Male
Race
<None>
African American
Asian
Caucasian
Hispanic
Indian
Native American
Polish
*
Home E-Mail
*
Mobile Phone
Mobile 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>
Jr
Title
<None>
Dr.
Miss
Mr.
Mrs.
Ms.
Rev.
Gender
<None>
Female
Male
Race
<None>
African American
Asian
Caucasian
Hispanic
Indian
Native American
Polish
*
Home E-Mail
*
Mobile Phone
Mobile 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
*
Mobile Phone
Mobile 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>
Jr
Title
<None>
Dr.
Miss
Mr.
Mrs.
Ms.
Rev.
Gender
<None>
Female
Male
Race
<None>
African American
Asian
Caucasian
Hispanic
Indian
Native American
Polish
*
Home E-Mail
*
Mobile Phone
Mobile 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>
Jr
Title
<None>
Dr.
Miss
Mr.
Mrs.
Ms.
Rev.
Gender
<None>
Female
Male
Race
<None>
African American
Asian
Caucasian
Hispanic
Indian
Native American
Polish
*
Home E-Mail
*
Mobile Phone
Mobile 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
Grandchild
Is Emergency Contact
Home Phone
Is Allowed to Pickup
Business Phone
Pickup License
*
Mobile Phone
Pickup Tag
Pickup Notes
Contact 2
*
Last Name
*
First Name
*
Relation
<None>
Aunt
Friend
Grandparent
Spouse
Brother
Father
Mother
Uncle
Sister
Grandchild
Is Emergency Contact
Home Phone
Is Allowed to Pickup
Business Phone
Pickup License
*
Mobile Phone
Pickup Tag
Pickup Notes
Contact 3
*
Last Name
*
First Name
*
Relation
<None>
Aunt
Friend
Grandparent
Spouse
Brother
Father
Mother
Uncle
Sister
Grandchild
Is Emergency Contact
Home Phone
Is Allowed to Pickup
Business Phone
Pickup License
*
Mobile Phone
Pickup Tag
Pickup Notes
Medical Contacts
Physician
Physician Phone Number
Hospital
Hospital Phone Number
Insurance
Insurance Phone Number
Finished
Confirmation E-Mail address:
Please press the save button to submit the new student application.
