Language
Spanish (Latin America)
English (US)
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
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Gender
*
Current School Name & District
*
Current Grade
*
Race/Ethnicity
Please Select
African American
Asian
Filipino
Hispanic
Multiracial
Native American
Pacific Islander
White
OPTIONAL
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Parent/Guardian Contact Information
Parent/Guardian Name
*
First Name
Last Name
Suffix
Home Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Relationship to Child
*
Home Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent Email
*
example@example.com
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Other Parent/Guardian Contact Information
Other Parent/Guardian Name
First Name
Last Name
Suffix
Home Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Relationship to Child
Home Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Parent Email
example@example.com
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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
*
Today's Date
*
-
Month
-
Day
Year
Date Picker Icon
How Did You Hear About Us?
*
Please Select
Friend
Current Family
Pastor Jerry
Radio
Internet
Other
Current Family Name
First Name
Last Name
Other
Has your child been referred to an/or for mental health services?
*
Yes
No
Date and description of Mental Health Services
I agree to provide Visible Men Academy permission to access ALL of my child’s student records
*
Yes
No
Please verify that you are human
*
Submit Application
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