ICPA EARLY START Registration

ICPA EARLY START Registration

HL Academy
Registration Fee Payment Plan

ICPA EARLY START Tuition - $5,480/year

Payment Option – 12 Month Plan

      -Deposit - $500 (due with Registration)

   -12 Months @ - $450

Sibling Discount

- 1st Sibling (add $342/month)

- 2nd Sibling (add $252/month)

- 3rd Sibling (add $228/month)
M.I.
Student Information
Name *

First Name Last Name
Birth Date *

Month Day Year
Gender
Ethnicity
Parent Email Address *
What grade will you be in the Fall? *
Have you previously applied to or attended this school?

Yes No
If yes, what year?
Current Residence Information
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Mother's Name *

First Name Last Name
Father's Name

First Name Last Name
Mom Cell Phone Number *

Area Code Phone Number
Dad Cell Phone Number

Area Code Phone Number

Emergency Contact 1
Emergency Contact 1 Name *

First Name Last Name
Emergency Contact 1 Cell Phone Number *

Area Code Phone Number
Emergency Contact 2
Emergency Contact 2 Name

First Name Last Name
Emergency Contact 2 Cell Phone Number

Area Code Phone Number
Physician and Medical Information
Name

First Name Last Name
Phone Number

Area Code Phone Number
Preferred Hospital
Insurance/Health Coverage (Company)
Please list any of the following: Current medications, Medication allergies, Food allergies, Chronic health concerns.
Please inform the office of any other vital information you think they may need to know in the event of an emergency. Thank you.

Previous School (If Any)
School Name
City
State
Date Started

Month Day Year
Date Ended

Month Day Year
Should be Empty: