Enrollment Form
  1. Last Name*
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  2. First Name*
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  3. M.I.
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  4. SSN (Last 4 Numbers Only)*
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  5. Date of Birth
    (mm/dd/yyyy)*
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  6. Age*
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  7. City of Birth*
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  8. State of Birth*
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  9. Gender*

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  10. This Student Hispanic/Latino*

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  11. Race (Select one or more)*




  12. Language most often spoken by the student?
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  13. Language that the student first acquired?
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  14. Internet Browser
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  15. Operating System
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  16. Address*
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  17. City*
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  18. State*
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  19. Zip Code*
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  20. Phone*
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  21. Cell Phone
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  22. Email*
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  23. Please select your session choice by preference :
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  24. Returning Student

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  25. Last School Attended*
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  26. Last Year Attended*
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  27. Identified for Special Education?

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  28. - If Yes,, Does Student have a current IEP?

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  29. Category of Placement
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  30. Is one parent a member of the Armed Forces on active duty?*
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  31. MOTHER CONTACT INFORMATION
  32. First Name
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  33. Last Name
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  34. Cell Phone
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  35. Work Phone
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  36. Home Phone
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  37. Address
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  38. City
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  39. State
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  40. Zip Code
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  41. Mother Contact Rights (check all that apply)



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  42. FATHER CONTACT INFORMATION
  43. First Name
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  44. Last Name
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  45. Cell Phone
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  46. Work Phone
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  47. Home Phone
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  48. Address
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  49. City
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  50. State
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  51. Zip Code
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  52. Father Contact Rights



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  53. GUARDIAN CONTACT INFORMATION
  54. First Name
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  55. Last Name
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  56. Cell Phone
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  57. Work Phone
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  58. Home Phone
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  59. Address
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  60. City
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  61. State
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  62. Zip Code
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  63. Guardian Contact righrts



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  64. EMERGENCY CONTACT INFORMATION
  65. First Name
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  66. Last Name
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  67. Relationship to Student
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  68. Cell Phone
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  69. Work Phone
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  70. Home Phone
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