Emerald School of Excellence Enrollment Application

Enrollment Application Form

Application for enrollment consideration. Please tell us more about your prospective student and family below.
Student Information
Student Name*

First NameMiddle NameLast Name
Birth Date*

MonthDayYear
Gender*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student E-mail*
example@example.com
Mobile Number*
Previous Treatment Programs (check all that apply)*

Short Term ResidentialLong Term ResidentialIndividual CounselingGroup CounselingMedication AssistedOutpatient TreatmentOther
Grade Level:*
Previous School:*
Student Ethnicity/Race:*
Student resides with:*
Counselor Name:
Recovery Support Name:
Parent/Guardian Information 1
Parent Name*

First NameMiddle NameLast Name
Phone Number*
Work Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer
Occupation
Are you the student’s legal guardian?*
Parent/Guardian Information 2
Parent Name*

First NameMiddle NameLast Name
Phone Number*
Work Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer
Occupation
Are you the student’s legal guardian?*
Additional Comments
Should be Empty:

Enrollment Application Form