Lifeline Learning Application for Enrollment

Registration Form

Please complete this form in its entirety. Once completed, our director will be in touch with you about next steps.
Student Name*

First NameMiddle NameLast Name
Parent #1 Name*

First NameMiddle NameLast Name
Parent #1 Phone Number*
Parent #1 E-mail*
example@example.com
Parent #2 Name

First NameMiddle NameLast Name
Parent #2 Phone Number
Parent #2 E-mail
example@example.com
Student Age *
Student Birth Date*

MonthDayYear
Student Gender*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student E-mail
example@example.com

Last School Attended *
Last grade successfully completed.*
Parent Place of Employment *
Position *
Church currently attending
Family Doctor*
Family Doctor Phone*
Known allergies of child*
Which immunizations has child received?*

PolioDTP/DTaP/DT/TdMMRHepatitis BVaricellaNone of these

Has student ever been expelled, dismissed, suspended, or refused admission from another school? If yes, please explain. *
Has student ever experienced disciplinary difficulty at school? If yes, please explain. *
Does the student have a juvenile arrest record?*
Has the student ever used tobacco or nonprescription drugs of any kind?*
Has student ever failed an academic subject?*
Please indicate academic level of student's previous work?*

ExcellentGoodAveragePoor
If two parents possess legal custody of child, which parents authorize this application?*
How did you hear about Lifeline Learning? *
Why did you decide to apply for Lifeline Learning*

Registration Form