Today's Date ___________________________

Enrollment Application 
Please print or type all information

Applicant Information:

Student Name (as it appears on birth certificate):

Last: __________________________ First: ____________________ Middle: ___________

Name your child goes by: ___________________________________ Gender: Male/Female

School District student lives in: _______________________________

Address: _____________________ City: ________________ State: _____  Zip: _________

Home Phone Number: (      )______________________

Date of Birth: _________  Place of Birth: _______________________________ Age: _____

(as it appears on birth certificate)                    

Ethnicity: African American / Asian / Caucasian / Hispanic / Native American/ Other: _____

Previous School Attended: _____________________________  Last grade completed _____

Parent/Legal Guardian Information:

Parent/Legal Guardian Name (1): __________________________ Relationship:_____________

Address: ________________________ City: ________________ State: _____  Zip: _________

Home Phone Number: (      )___________________ Work Phone: (      )____________________

Cell Phone Number :   (      )_________________   Pager Number: (      )___________________

Work Place: ______________________________ Hours of employment: __________________

Parent/Legal Guardian Name (2): __________________________ Relationship:_____________

Address: ________________________ City: ________________ State: _____  Zip: _________

Home Phone Number: (      )___________________ Work Phone: (      )____________________

Cell Phone Number :   (      )_________________   Pager Number: (      )___________________

Work Place: ______________________________ Hours of employment: __________________

Student resides with: □  Both Parents   □ Mother   □ Father   □ Guardian     □ Other _________________