STUDENT INFORMATION

Student Name (First, MI) *

Student Name (Last) *

Student Phone 1 *

Date of Birth * +

Student ID # *

Student Street Address *

City *

State * 🛈

Zip *

PARENT/GUARDIAN INFORMATION

Parent/Guardian's Full Name *

Parent/Guardian's Email *

Parent/Guardian's Phone 1 *

Parent/Guardian Street Address *

Parent/Guardian City *

State * 🛈

Parent Zip *

Last School *

Student has

IEP

504

Session *

Counselor Name

Classes will

be selected

by Counselor

Student & Parent Agreement *

Yes, I agree to fees, timelines & allowed courses within the Information Packet

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