Admission

Child’s Last Name:

Child’s First Name:

Child’s Date of Birth:

Child’s Current Grade:

Child’s Current School:

Mother’s Last Name:

Mother’s First Name:

Father’s Last Name:

Father’s First Name:

Legal Guardian’s Name:

Legal Guardian’s Cell#:

Home Phone:

Cell #:

Work #:

Home Address:

City:

Zip Code:

Mother’s Email:

Father’s Email:

Does Child have McKay?

Does Child have Step Up for Students?

Does Child have a documented disability?

How did you hear about us?