Contact Us

Enroll a Student > Registration Form

You may fill out the form below or download and print the application form and mail it in. The printable form will open in a new window. You can also visit us in our office and pick up an application.

When submitting your application, please attach a copy of your child's most recent report card, along with any standardized test scores or progress reports.

Because the information requested is vital to the safe and effective operation of our programs, incomplete applications will not be accepted. Thank you for your cooperation.

Please note, the information you provide in the application will be kept confidential and will be used for internal tracking purposes only.

Family Information
Student's First Name:
Student's Last Name:
Date of Birth:   (mm/dd/yyyy — e.g., 12/20/1970)
Gender:Male  Female
Race (optional):
Country of Origin:
Guardian's First Name:
Guardian's Last Name:
Relation to Child:
Guardian's Occupation:
Employer/School:
Languages Spoken at Home:
 
Full Mailing Address
Street1:
Street2:
City:
State:   Zipcode:
 
Day Phone:
Evening Phone:
Fax:
Email Address:
 
Emergency Contact Information (Please list two names and ALL applicable phone numbers)
Contact 1:
Contact 2:
Known allergies:
Other medical conditions:
Health insurance provider:
Identification number:
 
School/After-School Information
School attending:
Grade currently in:
 
Does your child participate in a billingual program?
Yes  No
If yes, which one?
 
What after-school program(s) is your child involved with?
 
What academic area(s)/subject(s) does your child need help with?
 
Has your child ever been referred to Special Education?
Yes  No
If yes, what year?
 
Does your child have an IEP?
Yes  No
 
Has you child ever been retained?
Yes  No
If yes, in what grade(s)?
 
Is there anything else you feel we should know about your child?
Please select the program(s) in which you are interested. Feel free to select more than one program.
 Specify which one: