Student Information
Name of student #1.
*
First Name
Middle Name
Last Name
Suffix
Date of birth - Student #1
*
Age - Student #1
*
Gender - Student #1
*
Male
Female
Grade for the 2024-2025 School Year - Student #1
*
Name of the Last School Attended - Student #1
*
Address of School (last school attended) Student #1
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of Student #2.
First Name
Middle Name
Last Name
Suffix
Date of Birth - Student #2
-
Month
-
Day
Year
Date
Age - Student #2
Gender - Student #2
Female
Male
Grade for the 2024-2025 School Year - Student #2
Name of Last School attended - Student #2
Address of School (last school attended) - Student #2
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Name of primary parent
*
First Name
Middle Name
Last Name
Primary parent
*
Mother
Father
Guardian
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of secondary parent
*
First Name
Middle Name
Last Name
Secondary parent
*
Mother
Father
Guardian
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Tuition Payment Iinformation
Does your child have any allergies, please list all allergies:
Does your child take any medications?
Does your child have a current IEP?
Yes
No
If yes, list the diagnosis below:
Emergency Contact (Name, email, and number):
Tuition Payments (Check all that apply)
ESA Funding (must be paid quarterly)
Credit card (banking fee applied, auto-pay)
ACH Transfer (no fee for auto-pay)
STO Scholarship (www.schoolchoicearizona.org)
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Submit
Date
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Signature
Continue
Continue
Should be Empty: