Enrollment Form

Student Details:

Child's First Name

Child's Middle Name

Child's Last Name

Gender

Male

Female

Birthday

Country of Birth

State of Birth

Ethnicity: Is the student of Hispanic or Latino origin?

Yes

* Racial and ethnic categories conform to Department of Education required reporting specifications.

Mailing Address

Primary Phone Number

Current School Information:

Current School

Family Information:

Parent/Legal Guardian 1:

First Name

Middle Name

Relationship to Student

Home Phone

Mobile Phone

Last Name

If living separately, please provide your mailing address:

Employment Information

Parent/Legal Guardian 2:

First Name

Middle Name

Relationship to Student

Home Phone

Mobile Phone

Last Name

If living separately, please provide your mailing address:

Employment Information

Any concerns about your child that we should be aware of

Name of the referring student, if any

Signatures:

Parent(s)/Guardian(s):

I(We) affirm that all information presented in conjunction with the application process is true and complete. I(We) understand Young Champions relies on the material accuracy of all information provided in conjunction with the application process, and any material inaccuracy or change in circumstances constitutes grounds for Young Champions to revoke admission or dismiss an enrolled student.

I(We) hereby request my child’s current school to release to Young Champions any information requested to complete the processing of this application. I(We) understand that if enrolled at Young Champions, the current school or I(We) will send my child’s full student records to Young Champions.

I(We) agree to pay non-refundable registration fee of $75 to Young Champions. This is one time payment to cover the cost of processing my child's application by Young Champions. This fee will not be refunded if my application is not approved. This fee will not be adjusted in the Tuition or any other fee. I(We) will be asked to pay this registration fee again if I(We) withdraw our child from Young Champions and re-enroll at a later time.

Signature of Parent/Legal Guardian 1

Date

Signature of Parent/Legal Guardian 2

Date