EmailMe Form - Homeschool Registration

Student Name *

First Last

Gender *

Male

Female

Date of Birth *

MM / DD / YYYY

NIB No. *

Age *

Parent/ Guardian Name *

Prefix First Last

Email *

Confirm

Cell Phone *

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

Work Phone *

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

Home Phone

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

Address *

Street Address City State / Province / Region Postal / Zip Code Country / Region

Religion *

This application is for enrollment as: *

Which type of program will you use? *

For which Term do you seek admission? *

Any medical conditions or disabilities? *

Yes

No

If yes, please explain.

Please tell us your reason for choosing to homeschool your child. *

Yes

Please explain: *

Last School attended *

Last GPA *

Tell us about your child: *

How did you learn about our program? *

If referred, name of the referrer?