Perry South Stark Career Academy Student Application for Enrollment
Identifying Information
Email address *
First Name *
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Middle Name *
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Last Name *
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Street Number and Name *
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City *
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Zip Code *
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Parent Phone Number *
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Gender *
Date of Birth *
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DD
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YYYY
Current Grade *
City in which you were born *
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Mother's Maiden Name *
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Ethnicity *
Are you on an IEP? *
Parent/Guardian 1 Name (with whom you live) *
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Parent/Guardian 1 Place of Employment *
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Parent/Guardian 1 Employment Address *
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Parent/Guardian 1 Employment Telephone *
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Parent/Guardian 1 Email Address *
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Parent/Guardian 2 Name (With whom you live)
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Parent/Guardian 2 Place of Employment
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Parent/Guardian 2 Employment Address
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Parent/Guardian 2 Employment Telephone
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Parent/Guardian 2 Email Address
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