Liberty Charter School Lottery Waiting List Record Please fill out one form for each student

Child's First Name *

Child's Last Name *

Student's Current Grade for 2012-2013 *

Please SelectPre-KKindergartenFirst GradeSecond GradeThird GradeFourth GradeFifth GradeSixth GradeSeventh GradeEighth GradeNinth GradeTenth GradeEleventh Grade

Next Year's Grade Level (2013-2014) *

Please SelectKindergartenFirst GradeSecond GradeThird GradeFourth GradeFifth GradeSixth GradeSeventh GradeEighth GradeNinth GradeTenth GradeEleventh GradeTwelfth Grade

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

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 *

### - ### - ####

Alternate Daytime Number

### - ### - ####

Email *

Confirm Email *

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