New Student Enrollment Form

Student First Name

Student Middle Name

Student Last Name

Date of Birth MM/DD/YYYY

Address Line 1

Address Line 2

City

State

Zip

Contact Name Primary caregiver's name.

Contact Email Address Confirmation email will be sent to this address.

Contact Phone

Grade Level

Does your child have an IEP? Currently receiving special education services or has in the past. Yes No

Special medical needs/allergies? An additional health information form will be completed at a later date. Yes No

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