Harper Hybrid Student Application
2020-2021 School Year
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Email *
Student Information:
Student - First Name *
Student - Last Name *
Student - Nickname
Student - Date of Birth *
MM
/
DD
/
YYYY
Student - Gender *
Does your Student have this school year (or last school year) an IEP (Individualized Learning Plan) or receive any special services through school or privately? *
If you answered yes to the IEP / special services question, please describe:
Does your Student have any medical conditions or history that Harper should know about in order to provide a healthy and safe school experience for your child? *
If you answered yes to the medical question, please describe:
Student - School District (where student would normally attend) *
Student - Name of Elementary School (where student would normally attend) *
2020-21 School Year:
Grade Level *
Harper Hybrid Schedule Choice: Full Day (8:30 am - 3:00 pm) or Half Day  (8:30 am - 12:15 pm) and How Many Days per Week *
If you chose less than 5 days per week, please indicate which days:
Extended Care: Mornings (7:45 am - 8:30 am) and afternoons (3:00 pm - 5:30 pm) *
Required
If you chose less than 5 days per week for extended care, please indicate which days:
Parent Information:
Parent #1 - Relationship to Applicant *
Parent #1 - First Name *
Parent #1 - Last Name *
Parent #1 - Mobile Phone Number *
Parent #1 - Home Street Address *
Parent #1 - City *
Parent #1 - State *
Parent #1 - Zip Code *
Parent #2 - Relationship to Applicant
Clear selection
Parent #2 - First Name
Parent #2 - Last Name
Parent #2 - Mobile Phone Number
Parent #2 - Email Address
Parent #2 - Home Street Address (if not same as Parent #1)
Parent #2 - City
Parent #2 - State
Parent #2 - Zip
A copy of your responses will be emailed to the address you provided.
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