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EXIT

IL San Mateo

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* 1. Student's Name

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* 2. Gender

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* 3. Student Date of Birth

Date

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* 4. Student Information

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* 5. Desire start date

Date

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* 6. School

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* 7. Does the student need transportation service?

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* 8. Does the student have a sibling currently enrolled or previously registered at our school?

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* 9. Program Option Days (Please Check)

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* 10. Home Address

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* 11. Guardian's Name

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* 13. Guardian's phone number

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* 14. Guardian's work address

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* 15. 2nd Guardian's Name

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* 17. 2nd Guardian's phone number

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* 18. 2nd Guardian's work address

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* 19. Have you previously applied to or attended this school?

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* 20. Does the student have any special needs or require any accommodations?

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* 21. Does the student have any allergies?

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* 22. Does the student have any medical conditions or take any medications?

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