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Kindergarten-12th Grade Registration Form
Anticipated Start Date:
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Last Name: *
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First Name: *
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Middle Name:
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Street Address: *
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City: *
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State: *
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Zip Code: *
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Primary Phone: *
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Date of Birth MM/DD/YYYY: *
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Gender: *
Grade *
Ethnicity: *
Father's Name:
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Father's Cell Phone:
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Father's Email:
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Father's Employer:
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Father's Occupation:
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Father's Work Phone:
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Mother's Name:
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Mother's Cell Phone:
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Mother's Email:
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Mother's Employer:
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Mother's Occupation:
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Mother's Work Phone:
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Guardian's Name:
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Guardian's Cell Phone:
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Guardian's Email:
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Guardian's Employer:
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Guardian's Occupation:
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Guardian Work Phone:
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Student Lives With: *
Sibling #1 Name:
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Sibling #1 Date of Birth:
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Sibling #2 Name:
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Sibling #2 Date of Birth:
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Sibling #3 Name:
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Sibling #3 Date of Birth:
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Sibling #4 Name:
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Sibling #4 Date of Birth:
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Sibling #5 Name:
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Sibling #5 Date of Birth:
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Individualized Education Plan (IEP) *
Disability
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