Student’s Full Legal Name *

Date of birth *

Student’s Gender *

Grade Entering for 2025-2026 *

Father’s Full Name *

Father's Email Address

Father's Phone

Mother’s Full Name *

Mother's Email Address *

Mother's Phone *

Guardians(s), If different from Parents

Street Address *

City *

State *

Postal code *

With whom does student live

Both Parents

Father

Mother

Guardian(s)

Religious Affiliation

Are you interested in Latchkey/After School Program? *

Yes

Any additional message you would like to share