Enrollment Form

Enrollment Form
Parent's Name

First Name Last Name
Parent's Email
example@example.com
Student's Name*

First Name Last Name
Student's Nickname
Gender*

MaleFemale
Grade*
Birthdate*

MonthDay Year
Date
Phone Number*

Area Code Phone Number
Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Mailing Address (If different from above)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Race*

African American/BlackAsianHispanicNative American/AlaskanNative Hawaiian or Pacific IslanderWhite
Hispanic or Latino Ethnicity*

YesNo
Language Spoken at Home*

EnglishSpanishFrenchCreole
Birthplace*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Student's Transportation*

WalkBusCarCarpool
Student Lives WIth*

Both ParentsStep ParentMother OnlyFather OnlyFoster CareGrand ParentGuardian
Documentation Required*

Surrogate ParentsLegal GuardianGuardian Ad Litem
Has student ever been expelled from any school, had an arrest which resulted in a charge, had any other Department of Juvenile Justice actions against him/her, or been referred for mental health services?*

YesNo
If Yes, please describe
Migrant Farmer Worker*

YesNo
If yes, do you travel in FL or to other states to find farm work?

YesNo
Mother's Name on Birth Certificate*

First Name Last Name
Father's Name on Birth Certificate*

First Name Last Name
Brothers/Sisters Attending School
First Name Last Name Grade Student ID School Name
Brothers/Sisters Attending School
First Name Last Name Grade Student ID School Name
Brothers/Sisters Attending School
First Name Last Name Grade Student ID School Name
Brothers/Sisters Attending School
First Name Last Name Grade Student ID School Name
Has student been in an exceptional student education (ESE) or any other special education program?*

YesNo
Has student been determined eligible under Section 504 and/or has a Section 504 plan?*

YesNo
Has student been in any ESOL or ELL program or class?*

YesNo
Is your family residing in any of the following situations?

Sharing the housing of others due to loss of housing or economic hardship.Living in a motel or hotel due to loss of housing or economic hardship.Staying in a shelterSubstandard housing; without electricity, running water, health code violations, etc.Sleeping in a car, campground, park or public space.
Are you the legal parent or guardian of the student?*

YesNo
Has child repeated any grades? If yes, which grades?
Has student ever attended a Florida school?
Grade Student ID School Name
Give the name, complete address of the last school attended.

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Give the Phone Number of the last school attended.

Area Code Phone Number
Did student complete kindergarten?*

YesNo
Years in school, including kindergarten prior to current year.*
Did the child complete a VPK Program?*

YesNo
Student's Birth Certificate

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Parent's Driver's License/ID

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Physical Form

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Immunization Forms

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Proof of Residency

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2 forms Lease, Bank Statement, Vehicle Registration, etc. Cancelof
Withdrawal/Transfer Form

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Prior School Records

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Signature

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Non-Refundable Enrollment Fee Deposit. *

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Payment Methods

Debit or Credit Card

First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Please click one of the PayPal options to complete payment and submit the form.

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