Student Basic Information
Legal First Name: Legal Last Name:
Preferred Name: Middle Name:
Gender: Date of Birth:
   
Notes:    
 

Student Address
Street: City:
State: County:
ZIP: Race:
Student Email: Hispanic:
Phone: Country of Birth:
   

Academic
Grade Level at time of Upcoming Semester:
Local School Name:
   

Guardians
Guardian 1 Guardian 2
Relationship: Relationship:
Last Name: Last Name:
First Name: First Name:
Email*: Email:
Phone: Phone:
*Guardian email must be different from email entered for student.    

Student Additional Information
English Language Learner (ELL): Current IEP:
Current Section 504: