Enrollment Application
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PARENT INFORMATION
Your Parental Status
*
Select
Father
Mother
Step Parent
Legal Guardian
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List is empty.
Full Name
*
Address
*
Street Address
*
City
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State
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Country
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic of the
Cook Islands
Costa Rica
Cote D"Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic Of
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea People's Democratic Republic
Republic of Korea
Kuwait
Kyrgyzstan
Land Islands
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
North Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Federated States of Micronesia
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Eswatini
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania, United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
UK
Ukraine
United Arab Emirates
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
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Postal Code
*
Mobile Phone Number
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Email
*
Place of Birth (City & ST)
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Date Of Birth
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Social Security Number
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Marital Status
*
Single
Married
Separated
Divorced
Widowed
Are You Currently Employed?
*
Yes
No
Employer
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Occupation
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Work Phone
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Are you the Primary Guardian?
*
Yes
No
Is there any other Parent, Legal Guardian or Authorized Caretaker?
*
Yes
No
Parent, Legal Guardian or Authorized Caretaker Role
*
Select
Spouse
Step Father
Step Mother
Grandparent
Legal Guardian
Foster Parent
Authorized Caretaker
Other
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List is empty.
Parent, Legal Guardian or Authorized Caretaker Role (Other)
*
SPOUSE INFORMATION
Do you & your spouse reside in the same household?
*
Yes
No
Spouse's Full Name
Spouse's Street Address
Spouse's City
Spouse's State
Spouse's Postal Code
Spouse's Email
Spouse's Mobile Number
Spouse's Date of Birth
Spouse's Place of Birth (City & State)
Spouse's Employer
Spouse's Occupation
Spouse's Work Phone
Is this Spouse a Primary or Secondary Guardian?
Select
Primary Guardian
Secondary Guardian
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OTHER PARENT OR LEGAL GUARDIAN INFORMATION (2)
Legal Guardian Full Name
Legal Guardian Street Address
Legal Guardian City
Legal Guardian State
Legal Guardian Postal Code
Legal Guardian Email
Legal Guardian Mobile Phone Number
Legal Guardian Date of Birth
Legal Guardian Place of Birth (City & State)
Legal Guardian Employer
Legal Guardian Occupation
Legal Guardian Work Phone
Is this Legal Guardian an Emergency Contact?
Yes
No
CHILD'S INFORMATION
Child Full Name
*
Date of Birth (DOB)
Who Does the Child Lives With?
Select
Same Household with Married Parents
With Father
With Mother
With Stepfather
With Stepmother
With Grandparent(s)
With Legal Guardian
Other
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Who Has Legal Custody of the Child?
Select
Both Mother & Father as Married Parents
Both Mother & Father with Split Custody
Father (Full Custody)
Mother (Full Custody)
Stepmother (with Father)
Stepmother (Individually)
Stepfather (with Mother)
Stepfather (Individually)
Grandparents
Legal Guardian
Other
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List is empty.
Child Identifier
*
Does Child Have Any Siblings?
*
Yes
No
How Many Siblings Does Child Have?
*
Select
1
2
3
4
5+
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SIBLING (#1)
Sibling (1): Name
Sibling (1): Age
Sibling (1): Grade
Sibling (1): School
SIBLING (#2)
Sibling (2): Name
Sibling (2): Age
Sibling (2): Grade
Sibling (2): School
SIBLING (#3)
Sibling (3): Name
Sibling (3): Age
Sibling (3): Grade
Sibling (3): School
SIBLING (#4)
Sibling (4): Name
Sibling (4): Age
Sibling (4): Grade
Sibling (4): School
CHILD'S MEDICAL & EMERGENCY INFORMATION
Does Child Have Any Allergies?
*
Yes
No
Please List All Child's Allergies (1 Per Line)
*
Are You Providing Child With an Inhaler?
*
Yes
No
Are You Providing Child With an Epipen?
*
Yes
No
Are You Providing Child With Any Medications?
*
Yes
No
Which Medications Are You Providing Child With? (1 Per Line)
*
Please describe any illnesses, diseases, mental, emotional or physical disabilities which may affect your child’s general progress or participation in the classroom or in any other school related activities (If Applicable)::
*
Has Child Ever Been Tested For a Learning Disability and/or Attention Deficit Disorder?
*
Yes
No
Please Upload Any & All Result Documents from Learning Disability and/or Attention Deficit Disorder Testing:
*
PHYSICIAN & INSURANCE INFORMATION
Medical Doctor or Office Name
*
Medical Doctor or Office Phone
*
Dentist or Dental Office Name
*
Dentist or Dental Office Phone
*
Preferred Hospital
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Preferred Hospital Phone
*
Insurance Carrier Name
*
Insurance Policy Number
*
Insurance Group Number
*
Insurance Carrier Phone Number
*
