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