iCAN (Canyons Academy North) Application Form
** IMPORTANT: Please refer to the APPLICATION PACKET instructions to complete the application process. Completion of this form is only one part of the process. **

All information on this form is CONFIDENTIAL.

Application deadline is FRIDAY, February 15, 2019.

Email address *
1. Student LEGAL Last Name *
Your answer
2. Student LEGAL First Name *
Your answer
3. Student LEGAL Middle Name *
Your answer
4. Birthdate (mm/dd/yyyy) *
Your answer
5. Current Junior High School *
6. Hart District School ID # (Enter NONE if you are a non-district student) *
Your answer
7. Does student have a 504 Plan? *
8. Does student have an IEP? *
9. Primary address where student resides (Street number with apt/space number) *
Your answer
10. City *
11. Zip Code *
Your answer
12. Home Phone Number (xxx-xxx-xxxx) *
Your answer
13. (1) Name of Parent/Guardian *
Your answer
14. Parent/Guardian Address (Note same as student or or add if different than student) *
Your answer
15. Cell Phone Number (xxx-xxx-xxxx) *
Your answer
16. Work Phone Number (xxx-xxx-xxxx)
Your answer
17. Parent Email Address *
Your answer
18. (2) Name of Parent/Guardian
Your answer
19. Parent/Guardian Address (Note same as student or add if different than student)
Your answer
20. Cell Phone Number (xxx-xxx-xxxx)
Your answer
21. Work Phone Number (xxx-xxx-xxxx)
Your answer
22. Parent Email *
Your answer
Application DEADLINE is Friday, February 15, 2019 at 4 p.m.
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