International Language Academy of Detroit Interest Form
20434 W. Seven Mile Rd., Detroit, MI 48219
Date
-
Month
-
Day
Year
Date
Name of Student
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Age
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Ethnicity
Please Select
African American
Asian
Caucasian
Hispanic
Multi-Racial
Native American
Gender
Male
Female
Desired start date
-
Month
-
Day
Year
Date
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Next
Family Information
Student Lives With
Both Parents
Mother
Father
Appointed Legal Guardian (neither parents)
Name of Mother
First Name
Last Name
Email
*
example@example.com
Occupation
Cell Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address (if not same as above)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of Father
First Name
Last Name
Email
*
example@example.com
Occupation
Cell Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address (if not same as child)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of Legal Guardian
First Name
Last Name
Email
*
example@example.com
Occupation
Cell Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address (if not same as child)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
Medical and Health Information
Is your child taking any medications at home or at school?
*
Yes
No
Please provide details
Does your Child have any allergies to any of the following: Insect Bites, Food, Seasonal Allergies, Latex, Medicine, etc.
Yes
No
Please provide details
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Next
Financial Support
Is your child currently enrolled in the DHS program?
Yes
No
Do you plan on applying?
Yes
No
How many DHS hours did you receive?
Submit
Should be Empty: