VMA Student Enrollment Application

Student Enrollment Application
School Year *
Student Information
Name of Student *

First Name Middle Name Last Name Suffix
Student Address *

Street Address

Street Address Line 2

City State

Zip Code
Date of Birth *

Month Day Year
Gender *
Current School Name & District *
Current Grade *
Race/Ethinicity
OPTIONAL

Parent/Guardian Contact Information
Parent/Guardian Name *

First Name Last Name Suffix
Home Address *

Street Address

Street Address Line 2

City State

Zip Code
Relationship to Child *
Home Phone Number *
Please enter a valid phone number.
Cell Phone Number *
Please enter a valid phone number.
Work Phone Number *
Please enter a valid phone number.
Parent Email *
example@example.com

Other Parent/Guardian Contact Information
Other Parent/Guardian Name

First Name Last Name Suffix
Home Address

Street Address

Street Address Line 2

City State

Zip Code
Relationship to Child
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Parent Email
example@example.com

Additional Student Information
Which of the following programs has your child been a participant?

Special Education Limited English Proficiency/Bilingual Free/Reduced Lunch
Is there any other information you would like VMA to know about your child?
Parent/Guardian Signature *

Clear
Today's Date *

Month Day Year
Please verify that you are human *
Should be Empty: