Enrollment Interest Form

Student First Name

Student Last Name

Preferred Name (if different)

Date Of Birth

Gender

Male Female

Desired Enrollment Term

Fall 2025 Spring 2026 Summer 2026

Parent First Name

Parent Last Name

Relationship To Student

Mother Father Guardian Other

Primary Phone Number

Email Address

Home Address

City

State

Zip Code

Last School Attended

School Location

Reason For Leaving

Has the student repeated a grade?

Yes No

If yes, which grade?

Does the student have an IEP/504?

Yes No

If yes, please attach a copy

Primary Diagnoses/Areas of Service

Support Services Provided (e.g., speech, OT, counseling)

Modifications/Accommodations Needed

IEP Expiration Date

Upload most recent IEP documentation

Primary Care Physician Name

Physician Phone Number

Known Allergies or Medical Conditions (If none, enter "N/A")

Emergency Contact Name (other than parent)

Emergency Contact Relationship to Student

Emergency Contact Phone Number

Emergency Contact Email Address