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.

Primary Phone Number

Mailing Address

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) understand that submission of this form is not a guarantee of admission. Young Champions will review this information and will get back to me(us) to confirm the availability and further paperwork about agreement, policies and payments for us to review and sign before my(our) child is formally registered.

Signature of Parent/Legal Guardian 1

Date

Signature of Parent/Legal Guardian 2

Date