PDILA Express Enrollment

By completing this form, I attest that I have the custody and educational rights for this student.   YES     NO       

Student First Name   Student Last Name   

Parent First Name   Parent Last Name   

Student Date of Birth   

Physical: Street Address   Address Line 2   City   State   Zip   

Mailing: Street Address   Address Line 2   City   State   Zip

Area Code   Home Phone Number      

Area Code   Cell Phone Number   

Email   

Incoming Grade Level for 26-27*   

Student Race
Black   White    Asian   More than one racee   American Indian   Native Hawaiian or Pacific Islander     

PARENT ACKNOWLEDGEMENT
The information provided is accurate to my knowledge. Further, I understand it is my responsibility to notify the school in a timely manner related to changes in any information submitted in the contents of this enrollment packet.

Signature