2023-2024 Registration
Student Information
Student Name
Student Birthday
-
Month
-
Day
Year
Students between the ages of 14-21 may apply.
Address
Student Address
Street Address Line 2
City/State
State / Province
Zip
Student Phone Number
Student Email Address
example@example.com
Name of Last School Attended
Last Grade Level Attempted
Please Select
8th
9th
10th
11th
12th
unsure
Parent/Guardian/Adult Student Signature
Today's Date
-
Month
-
Day
Year
Date
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Student Demographic Information
Race
Please Select
Asian
Black
American Indian/Alaska Native
Hawaiian
White
Decline to Answer
Main Language Spoken at Home (By Student)
Please Select
English
Spanish
Other
Decline to Answer
Does the student have an IEP or receive special services?
Please Select
Yes
No
Unsure
Has the student received classroom accommodations under a 504 Plan?
Please Select
Yes
No
Unsure
Parent/Guardian Information
Required for students under 18 years old
Parent/Guardian Name
Parent/Guardian Phone Number
Relationship to Student
Please Select
Parent
Grandparent
Guardian
Foster Parent
Self
2nd Parent/Guardian Name
Not required
2nd Parent/Guardian Phone Number
Not required
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Emergency Medical Form
Emergency Contact
Relationship
Best Contact Number
I give my consent for treatment in the event I can not be reached.
Please Select
Yes
No
List preferred doctors and hospital below
Doctor Name
Hospital Name
Cleveland Clinic - Marymount Hospital is closest hospital
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Enrollment Documents
You can upload a photo of your document or let us assist you in collecting the paperwork for enrollment.
Upload Proof of Residency
Browse Files
Drag and drop files here
Choose a file
Lease, Utility (Gas, Water, Electric, Sewer) Bill, Court Records, Deed
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of
Upload Birth Certificate
Browse Files
Drag and drop files here
Choose a file
We can order you a birth certificate if you do not have one
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of
Submit
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