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Student Enrolment Form






Primary Contact

Primary Contact Person Full Name        

Primary Contact Person Email Address

Relationship to Student                           


Student Information

Name(Last/First/Middle):

Home Address:

City/State/Zip

Home Phone:

Country of Birth

Age:

Is the student under expulsion from another school:

Yes No 

Present School Attending

City/State

Phone Number

Check All that Apply

Regular Ed Special Ed Other 

Has student been recommended or referred for an IEP or testing of any kind? Yes No (If yes, please explain):

Yes No 


Legal Parent/Guardian Information

Mother’s Name (Last,First)

Marital Status

Home Address

Place of Birth

City/State/Zip

Country/Citizenship

Home Phone

Cell Phone

Employer

Work Phone

With whom does the child leave

Email Address

Father’s Name (Last,First)

Marital Status

Home Address

Place of Birth

City/State/Zip

Country/Citizenship

Home Phone

Cell Phone

Employer

Work Phone

With whom does the child leave

Email Address


Health Information

Is your Child Taking Medication? Yes No                                     Type of Medication

Purpose for Taking:                              Asthma/Allergies/Other


Student Sibling Information

Sibling Name  Enrolled here ? Yes No 

Sibling Name  Enrolled here ?  Yes No

Sibling Name  Enrolled here ?  Yes No


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