Course Registration Form

Grace Homelife Academy

2025-2026 School Year
Student Name

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Gender
Male or Female
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail
example@example.com
Mobile Number
Phone Number
Work Number
Schedule Preference
Type # of Days per week
Grade Level
Additional Comments
Should be Empty: