Registration Form
Program enrolling in: *
First Name *
Last Name *
Date of Birth *
MM
/
DD
/
YYYY
Phone number *
Address (include city and zip code) *
Email *
Economic Special needs/ Personal status Check all that apply *
Required
Marital Status *
Ethnicity
Clear selection
Annual Income *
Number of dependents *
Number of children in grades K-12
Clear selection
Primary Language *
Labor Force *
Last School Attended - Include city and last year enrolled
Do you have access to any of the following: Check all that apply *
Required
Check which type of instruction you would prefer: *
Required
Are you familiar with google classroom? *
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