Liberty Charter School Lottery Waiting List Record
Child's First Name *
Child's Last Name *
Student's Current Grade for 2011-2012 *
Next Year's Grade Level (2012-2013) *
Student's Current Age *
Student's Birthdate *

MM		/
DD		/
YYYY
Student Gender
 Male 
 Female 
School Year child will enter Kindergarten (must be 5 years old by Sept. 1 of that year:
Father's Name

First
Last
Mother's Name

First
Last
Address *

Street Address

Address Line 2

City
State / Province / Region

Postal / Zip Code
Country
Home Phone *

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Alternate Daytime Number

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Email *
Confirm Email *

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