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
Format: (000) 000-0000.
Parent #1 E-mail
example@example.com
Parent #2 Name

First NameMiddle NameLast Name
Parent #2 Phone Number
Format: (000) 000-0000.
Parent #2 E-mail
example@example.com
Student Age
Student Birth Date

MonthDayYear
Student Gender
Address

Street Address

Street Address Line 2

CityState / Province

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

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?
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