Parent or Guardian Name *

Parent's or Legal Guardian's Name

First Name

Last Name

Parent or Guardian Phone *

Parent or Guardian Phone Number for Registration follow-up or Emergencies

(###)

###

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Address *

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact *

Emergency Contact other than above.

First Name

Last Name

Emergency Contact Phone *

Emergency Contact Phone

(###)

###

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Student's Name *

Student's Name

First Name

Last Name

Student's Date of Birth

MM

DD

YYYY

Financial Assistance

Please check the box if you would like to apply for financial assistance.

I have financial need and would like to apply for assistance.

Second Parent/Guardian Name

optional

First Name

Last Name

Second Parent/Guardian Phone

optional

(###)

###

####

Student Phone (optional)

(###)

###

####