Liberty Charter School Lottery Waiting List Record

Child's First Name *
Child's Last Name *
Student's Current Grade for 2012-2013 *
Next Year's Grade Level (2013-2014) *
Student's Current Age *
Student's Birthdate *

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Student Gender
 Male 
 Female 
School Year child will enter Kindergarten (must be 5 years old by Sept. 1 of that year:
Father's Name
Prefix
First
Last
Suffix
Mother's Name
Prefix
First
Last
Suffix
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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