STUDENT APPLICATION FORM 26/27

Student Application Form

There is a $225 application fee per child. This is nonrefundable.
Primary Guardian's First and Last Name*

First NameLast Name
Primary Guardian's Email Address*
example@example.com
Primary Guardian's Phone Number*
Please enter a valid phone number.
Secondary Guardian's First and Last Name

First NameLast Name
Secondary Guardian's Email Address
example@example.com
Secondary Guardian's Phone Number
Please enter a valid phone number.
Primary Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
STUDENT INFORMATION
How many children are you applying for?*

OneTwoThreeFour
Student #1 Name*

First NameLast Name
Student #1 Entering Grade Level*
Student #2 Name

First NameLast Name
Student #2 Entering Grade Level
Student #3 Name

First NameLast Name
Student #3 Entering Grade Level
Student #4 Name

First NameLast Name
Student #4 Entering Grade Level
EXTRACURRICULARS
Are you interested in enrolling your child(s) in Extracurriculars from Monday-Thursday from 1:15-3:00 for $600/quarter?*

YesNo
Are you interested in enrolling your child(s) in Before-School Care from Monday-Thursday from 7:40-8:40 for $500/child per quarter?*

YesNo
Are you interested in enrolling your child(s) in After-School Care from Monday-Thursday from 3:00-4:00 for $500/child per quarter?*

YesNo
Are you interested in enrolling your child in optional Fridays from 9:00-1:00 ONLY for $1,200 a year? (This day will be supervised by our licensed teachers to aid in your child(s) completion of Friday’s work and our Growth Factor business curriculum).*

YesNo
ABOUT YOUR CHILD(S)
What type of school are you currently enrolled in?*
In order to best serve your child, has your child(s) ever had an IEP, 504 or receive any outside services? If so, please explain.*
Tell us a little about your interest, expectations, and hopes for your child(s)’ school year. *
PAYMENT
How would you prefer to make tuition payments for the school year?*

My Products*

Application FeeThe Application Fee is $225 per child. Your child(s) will not be added to the official waitlist unless an application fee has been submitted for each kid.

$225.00 Quantity

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

I, First Name* Last Name* , understand that I am applying for my child(s) to be enrolled for the 2026-2027 Haven Academy school year by completing and submitting this form. I understand that the $225 application fee per child(s) is non-refundable.
Guardian Signature*

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Student Application Form