Student Enrollment Form

Instructions: Fill out the following information completely and sign and date the last page.
Notify us immediately if any of your information changes

Student Information

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1 Step 1

Legal Last Nameyour full name

Legal First Name

Legal Middle Name

Preferred Name

Date of Birth

date_range

MaleFemale

Home Address

City

State

Zip Code

Shipping Address (If different from Home Address)

City

State

Zip Code

Student’s Phone Number

MobileHome

Student’s Email Addressa valid email

email

Are you an eligible student who is 18 or older or an emancipated minor enrolling yourself?(if no, fill out parent/guardian information)

YES NO

Parent/Guardian Information

Primary Parent/Guardian Name

Relationship

RelationshipMotherFatherLegal Guardian

Legal Description

Home Address

City

State

Zip Code

Primary Parent/Guardian Email Address

email

Phone Number

MobileHomeWork

Secondary Phone Number

Type of Phone

MobileHomeWork

Preferred Method of Contact:

PhoneEmail

Best time of day to contact you?

MorningAfternoonEvening

Submit Form

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