Student Full Name *

First Name

Last Name

Birthdate *

MM

DD

YYYY

Parent Name 1 *

First Name

Last Name

Parent 1 Address *

Child's primary residence

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home/Cell Phone *

(###)

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Work Phone

(###)

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Parent 2 Name

First Name

Last Name

Is Parent 2 living at the same address as Parent 1? *

If the answer is "no," please enter Parent 2's residence below. If the answer is "yes," click "yes" and skip to Parent 2's phone number. If there is no Parent 2, select "yes" and skip to the next set of questions.

Yes

No

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home/Cell Phone

(###)

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Work Phone

(###)

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Primary Emergency Contact *

Non-parent contact in case of an emergency

First Name

Last Name

Home/Cell Phone: *

(###)

###

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Secondary Emergency Contact *

Non-parent contact in case of an emergency

First Name

Last Name

Home/Cell Phone: *

(###)

###

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Tertiary Emergency Contact

Non-parent contact in case of an emergency

First Name

Last Name

Home/Cell Phone:

(###)

###

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