Class Registration Signup Form

Visionary Leaders Academy Student Registration Form

Fill out the form carefully for registration
Student Name

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Grade
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent E-mail Address
Parent/Guardian

First NameLast Name
Mobile Number

Area CodePhone Number
Phone Number

Area CodePhone Number
Work Number

Area CodePhone Number
Company
Parent/Guardian

First NameLast Name
Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Work Number

Area CodePhone Number
Company
Emergency Contact

First NameLast Name
Phone Number

Area CodePhone Number
Relationship to Student
Emergency Contact

First NameLast Name
Phone Number

Area CodePhone Number
Relationship to Student
How many people (including children) reside at the address listed above?
Is one or more of the students in the household a ward of the court or a foster child
Is one or more of the students in this household a food stamp, FDPIR (Food Distribution Program on Indian Reservation), TANF (Temporary Assistance for Needy Families), or SNAP (Supplemental Nutrition Assistance Program) recipient?
I would like to receive a school provided computer (laptop)
Commonwealth Charter Academy requires a Household PIN to verify a parent or guardian identity during all communications involving student information. Please create your Household PIN by entering a number value (maximum 6 number characters) in the field below
I certify that I have the legal authority to make educational decisions for the student above
Should be Empty:

Visionary Leaders Academy Student Registration Form