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Online Enrollment Application


Student Information
Student's Full Name:
Student's Full Name:
Home Address:
Home Address:
Birthdate:
Birthdate:
Parent/Guardian Information #1
Parent/Guardian's Full Name:
Parent/Guardian's Full Name:
Home Address:
Home Address:
Home Phone:
Home Phone:
Cell Phone:
Cell Phone:
Employer Address:
Employer Address:
Work Phone:
Work Phone:
Parent/Guardian Information #2
Parent/Guardian's Full Name:
Parent/Guardian's Full Name:
Home Address:
Home Address:
Home Phone:
Home Phone:
Cell Phone:
Cell Phone:
Employer Address:
Employer Address:
Work Phone:
Work Phone:
Student Release Information
(not for emergency purposes - see Parent Handbook) Prior arrangements must be made with the Director or Staff Lead for the student to be released to any of the following individuals.
Individual #1:
Individual #1:
Phone:
Phone:
Individual #2:
Individual #2:
Phone:
Phone:
Individual #3:
Individual #3:
Phone:
Phone:
Emergency Information
In case of an emergency and parents/guardians can't be reached, the student may be released to the following:
Emergency Contact #1:
Emergency Contact #1:
Phone:
Phone:
Emergency Contact #2:
Emergency Contact #2:
Phone:
Phone:
Medical Information
Student's Primary Physician:
Student's Primary Physician:
Primary Physician's Address:
Primary Physician's Address:
Primary Physician's Phone:
Primary Physician's Phone: