Student Application
2021-2022 School Year
Email address *
Student Information:
Student - First Name *
Student - Last Name *
Student - Nickname
Student - Date of Birth *
MM
/
DD
/
YYYY
Student - Gender *
Student - Current School
2021-22 School Year:
Grade Level *
Days and Time - Toddler, Preschool, and Pre-kindergarten Applicants only (not K-6)
Clear selection
Extended Care
Clear selection
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
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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