Dierks School Choice Application 2023-2024
Applicant Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gener
Male
Female
Grade (for the 2023-2024 School Year)
Does the applicant require special needs or programs?
Yes
No
Ethnic Origin (Check One):
2 or More Races
African American
Native American/Native Alaskan
Asian
Native Hawaiian/Pacific Islander
Hispanic
White
Resident School District of Applicant (The name of the school district where you currently reside)
District County Name
District Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
District Phone Number
Please enter a valid phone number.
Parent/ Guardian Name
First Name
Last Name
Home Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Parent/Guardian Signature
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