GSA Pre-Registration Form

Parent/Guardian Information
Household 1

Information about the student's primary residence
Household 1 Physical Address*

Street Address

Street Address Line 2

CityState

Zip Code
Is the mailing address the same as the physical address?*

YesNo
Mailing Address (if different from physical address)

Mailing Address Line 1

Mailing Address Line 2

CityState

Zip Code
Parent/Guardian Name*

First NameLast Name
Email*
example@example.com
Phone*
Please enter a valid phone number.
Relationship to Student*

MotherFatherStep-ParentGrandparentGuardianOther
Additional Parent/Guardian Name (if applicable)

First NameLast Name
Email
example@example.com
Phone
Please enter a valid phone number.
Relationship to Student

MotherFatherStep-ParentGrandparentGuardianOther
Household 2

Information about the student's second residence, if applicable
Household 2 Physical Address

Street Address

Street Address Line 2

CityState

Zip Code
Is the mailing address the same as the physical address?

YesNo
Household 2 Mailing Address (if different from physical address)

Mailing Address Line 1

Mailing Address Line 2

CityState

Zip Code
Parent/Guardian Name

First NameLast Name
Email
example@example.com
Phone
Please enter a valid phone number.
Relationship to Student

MotherFatherGrandparentGuardianOther
Additional Parent/Guardian Name (if applicable)

First NameLast Name
Email
example@example.com
Phone
Please enter a valid phone number.
Relationship to Student

MotherFatherStep-ParentGrandparentGuardianOther

Additional Information
Does this student currently have paperwork on file with their district/school providing for learning accommodations?*

Yes, an IEP planYes, a 504 planNo
OPTIONAL: If you would like to provide the name and contact information of a teacher or guidance counselor who has worked with this student and can provide insight into their learning style and personality, we would love to speak with them

First NameLast Name
Email
Phone
Should be Empty: