Student's Legal Name *


Preferred Name *


Child's Date of Birth *


Gender *
Male
Female

Child's Citizenship *
United States
Other

Please provide a security code word. *


Street Address *


City *


State *


Zip *


Home Phone *


Your Email *


Family Information

Father/Guardian Full Name *


Home Phone


Cell Phone


Work Phone


Date of Birth *


Home Address (if different)


Employer *


Mother/Guardian *


Home Phone


Cell Phone


Work Phone


Date of Birth *


Home Address (if different)


Employer *


Family/Marital Relationship *
Together at Home
Seperated
Legally Divorced
Natural Mother Deceased
Natural Father Deceased

If parents are divorced, who has legal custody of child?


Is either parent forbidden by court order from having legal access to the child or the school records?
Yes
No

Attatch a copy of applicable court documents