2017-2018 Central Program Registration
Home High School
Last Name
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First Name
Your answer
Middle Initial
Your answer
Mailing Address (Street, Apt. Box No.)
Your answer
City
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State
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Zip
Your answer
Home Phone
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Parent Cell Phone
Your answer
Parent Email
Your answer
Student Email
Your answer
Parent/Guardian Last Name
Your answer
Parent/Guardian First Name
Your answer
Planned Date of Enrollment
Gender
Ethnic Origin
Are you Hispanic, Latino, or Spanish Origin?
Ethnic Origin
Date of Birth
MM
/
DD
/
YYYY
Current grade level
Birth State
Your answer
Graduation Year
Are you a new or returning CAVIAT student?
Student First Program Choice
Student Second Program Choice
Student Third Program Choice
Do you receive special education services at your home school?
Do you receive ELL services at your home school?
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