Student Registration Form

Omega Prep Academy

Sean Tarrant, Head Coach

470-577-5502

starrant@omegaprep.org

rtarrant@omegaprep.org

Basic Information
Student Registration Form
Full Name

First NameMiddle NameLast Name
Social Security Number
e.g. 11183021
Year Level
for Incoming A.Y. '12-'13
Sport
Email
Phone Number
Network Provider
Birth Date

MonthDayYear
Present Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Permanent Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent Contact

First NameLast Name
Relationship
ex. Father, Mother, etc.
Address Of Person To Contact In Case Of Emergency

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number Of Person To Contact In Case Of Emergency
Please enter a valid phone number.
Email Of Person To Contact In Case Of Emergency
example@example.com

Academic Background
High School Name
High School/College Transcripts

File should be in pdf, doc/docx format.
Cancelof
Other Extra Curricular Activities
Extra Curricular Participation

Student CouncilClass OfficerClub/OrganizationVarsity PlayerOthers (please specify below)