REGISTRATION FORM

REGISTRATION FORM

2023-2024 School Year
Family Information
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
County*
County
Home Phone Number*
Home Phone Number
First Parent/Guardian Information
Full Name*

Last NameFirst Name
Preferred Name*
Relationship to Student(s)*
Marital Status
Cell Phone*
Cell Phone Number
Email*
example@example.com
Occupation*
Employer*
Highest Level of Education*
Degree
Second Parent/Guardian Information
Full Name

Last NameFirst Name
Preferred Name
Relationship to Student(s)
Marital Status
Cell Phone
Cell Phone Number
Email
example@example.com
Occupation
Employer
Highest Level of Education
Degree
Number of Students Being Registered*
Student 1 Information
Student 1*

Last NameFirst Name
Preferred Name
Student 1 Date of Birth*

MonthDayYear
Student 1 Gender*
Student 1 Grade in 2023-24*
Transcript/Records Request for Student 1:

Please complete the following information that will allow us to request transcripts/records from your current school or umbrella school. We will need the name and email for the person in charge of records at your school or umbrella school.
Name of School/Umbrella School*
Transcript/Records Referral Name:*

First NameLast Name
Transcript/Records Request Email*
example@example.com
Student 2 Information
Student 2

Last NameFirst Name
Preferred Name
Date of Birth

MonthDayYear
Gender
Student 2 Grade in 2023-24
Transcript/Records Request for Student 2:

If this is the same school information as for Student 1, please leave blank.
Name of School/Umbrella School
Transcript/Records Referral Name:

First NameLast Name
Transcript/Records Request Email
example@example.com
Student 3 Information
Student 3

Last NameFirst Name
Preferred Name
Student 3 Date of Birth

MonthDayYear
Student 3 Gender
Student 3 Grade in 2023-24
Transcript/Records Request for Student 3:

If this is the same school information as for Student 1, please leave blank.
Name of School/Umbrella School
Transcript/Records Referral Name:

First NameLast Name
Transcript/Records Request Email
example@example.com
Student 4 Information
Student 4

Last NameFirst Name
Preferred Name
Student 4 Date of Birth

MonthDayYear
Student 4 Gender
Student 4 Grade in 2023-24
Transcript/Records Request for Student 4:

If this is the same school information as for Student 1, please leave blank.
Name of School/Umbrella School
Transcript/Records Referral Name:

First NameLast Name
Transcript/Records Request Email
example@example.com
Student 5 Information
Student 5

Last NameFirst Name
Preferred Name
Student 5 Date of Birth

MonthDayYear
Student 5 Gender
Student 5 Grade in 2023-24
Transcript/Records Request for Student 5:

If this is the same school information as for Student 1, please leave blank.
Name of School/Umbrella School
Transcript/Records Referral Name:

First NameLast Name
Transcript/Records Request Email
example@example.com
Anthem Umbrella School Fees (non-refundable and due at time of application):

Base Family Fee $95 per family

K-5th Grade + $25 per student

Family Cap $250

Select all that apply*

Base Family FeeOne per family

$95.00

K - 5th Grade Student FeeOne per student

$25.00 Quantity

Total

$0.00

Credit Card

Should be Empty:

REGISTRATION FORM

Family Information

First Parent/Guardian Information

Second Parent/Guardian Information

Student 1 Information

Student 2 Information

Student 3 Information

Student 4 Information

Student 5 Information

Credit Card