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Student Name*

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Email Address*

Phone Number

Area CodePhone Number

Transportation*

First Parent/Guardian school should contact:

Name

First NameLast Name

Relationship

Phone Number

Area CodePhone Number

E-mail

Health Information:

Family Doctor

First NameLast Name

Phone Number

Area CodePhone Number

Special Health Problems

I affirm that:

I have read and understood all the instructions in connection with my registrationI understand that all information I provide in this form may be used by the school and I consent to such with assurance that my personal details will be kept confidential

Signature

Student Registration form