Jasper Academy Registration Form

Jasper Academy Registration
Date

MonthDayYear
Date
Incoming Grade Level
Name of Student

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Name of Parent*

First NameLast Name
Parent Email Address*
Siblings
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Gender

MaleFemale
Would you like to register for the tuition-free program?*

YesNo
Can your child commit to attending 2 Black Cultural online assemblies?

(Attendance required for tuition-free scholarship)
Yes, they can commit or No, they cannot commit*

YesNo
Is this student learning disabled?

YesNo
Does you child currently use any of the following?*

IXL LearnngMobyMaxAbekaAcellusNone of the Above
Acknowledgement, Authorization, and Consent
By signing this form, I hereby authorize the school to use the information herein provided for the processing of my child's application.

I understand that the information shared herein shall be for the purpose of the admission of my child. I further declare that the information I have provided in this form is true and correct to the best of my knowledge.
Name

First NameLast Name
Date

MonthDayYear
Date
Should be Empty:

Jasper Academy Registration