DAY PROGRAM APPLICATION

Student Information

Address Where Student Lives

Scholastic

Race

Choose one or more:

Parent/Guardian Information

Mother

Father

Other Parent/Guardian

Contact Information

Please list the e-mail addresses below that you would like communications sent to in order of importance.

Additional Information

If you wish to provide any more documentation during this Intake Application, please use this upload field here.

Electronic Signature

The electronic signature below, and all of its related fields, replaces a handwritten signature on paper and is legally binding.

I affirm that the information provided is true, correct and complete, to the best of my knowledge and belief. This electronic signature below and its related fields are treated by like a handwritten signature on a paper form.

Parent/Guardian Signature

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