School Registration Form

IL Millbrae

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* 1. Student's Name

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* 2. Gender

Female

Male

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* 3. Desire start date

Date / Time

Date

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* 4. School

Meadows Elementary

Green Hill Elementary

Spring Valley Elementary

Lomita Park Elementary

Franklin Elementary

Lincoln Elementary

Hoover Elementary

McKinley Elementary

John Muir Elementary

Other (please specify)

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* 5. Does the student need transportation service?

Yes

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

Yes

If yes, please write the student's name.

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* 7. Home Address

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* 8. Student Date of Birth

Date

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* 9. Student Information

Year level

Semester

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* 10. Program Option Days (Please Check)

5 Days $655

4 days $635

3 days $615

If you choose the program for four or three days per week, please specify the fixed days, for example, M W TH.

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* 11. Mother’s Name(or guardian)

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* 12. Mother’s (or guardian) email address

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* 13. Mother’s (or guardian)phone

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* 14. Mother’s(or guardian) work address

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* 15. Father’s Name(or guardian)

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* 16. Father's (or guardian) email address

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* 17. Father’s (or guardian)phone

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* 18. Father’s (or guardian) work address

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

Yes

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

Yes

If yes, please describe in detail

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* 21. Does the student have any allergies?

Yes

If yes, please list

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

Yes

If yes, please describe: