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Thank you for your interest in our school!

Please fill out the form below and our Admissions Office will contact you and provide the information you desire.

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Parent/Guardian Information
*First Parent/Guardian
Salutation *

First Name *

Middle Name

Last Name *
Email Address *

Gender

Male Female
Work Phone

(Ex: 999-999-9999)

Cell Phone

(Ex: 999-999-9999)
Second Parent/Guardian
Salutation

First Name

Middle Name

Last Name
Email Address

Gender

Male Female
Work Phone

(Ex: 999-999-9999)

Cell Phone

(Ex: 999-999-9999)
How Did You Hear About Us?

Details:
Home Phone

(Ex: 999-999-9999)
Street Address
City
Country
State
Zip

Diagnosed Learning Differences:

	Dyslexia		Dysgraphia		Dyscalculia
	Expressive Receptive Language Disorder		ADD/ADHD		Other

If other, please list.
Student 1
First Name *

Middle Name

Last Name *
Birthdate *

(mm/dd/yyyy)

Email Address

Gender *

Male Female
Grade Level of Interest *

School Year *
Current School
Is There Another Student? Yes No
Parent/Guardian Notes

Type in the text that you see above (case sensitive):