Enrollment Form

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* 1. Student's Name

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* 2. Student's Date of Birth

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* 3. Student's Email

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* 4. Student's Grade Level

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* 5. Student's School

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* 6. Parent/Guardian's Name

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* 7. Parent/Guardian's Contact Information

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 8. Subject areas for growth

Subject

Subject

Subject

Subject

Subject

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* 9. List Specials Needs

IEP

504 Plan

Special Day Classes

None

Other (please specify)

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* 10. What online platform(s) does your school use?