BTE 21st CENTURY DISCOVERY INSTITUTE
Student Enrollment Form
Zoned School District:
Grade Level:
Student Information
Are you applying for enrollment as a Virtual Supervision Student?
Virtual Full Day
Student Name
First Name
Last Name
Preferred Name
With whom does the student reside?
Mother
Father
Both Parents
Legal Guardian
Birth Date:
/
Month
/
Day
Year
Date
Age:
Gender:
Address
Address
Street Address Line 2
City
State / Province
Zip
Does your child have a 504 plan or an IEP
504 Plan
IEP
No, my child does not have a 504 plan or an IEP
Does your child require any medications to be administered while at school?
Yes
No
Parent/Guardian Contact Information
Name of Parent/Guardian
Parent Email Address
example@example.com
Contact Number
-
Area Code
Phone Number
Emergency Contacts (Please lists adults authorized to check out student from school)
Name of Authorized Person
Home No.
Cell No.
IMPORTANT
Parent/Legal Guardian Signature
Date
/
Month
/
Day
Year
Date
Preview PDF
Submit
Should be Empty: