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LHS 9th Grade Registration 2012-2013
Contact Information
This survey is to be completed by the student, with assistance from a parent where appropriate.
25%
*
1.
Student Last Name
(Required.)
*
2.
Student First Name
(Required.)
3.
Student Middle Name
*
4.
Student Date of Birth (MM/DD/YYYY)
(Required.)
*
5.
Student Gender
(Required.)
Male
Female
*
6.
Please complete the following information.
(Required.)
Address:
*
City/Town:
*
ZIP:
*
Email Address (optional):
Phone Number (optional):