Private School Application Form

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* 1. Student name

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* 2. Student age

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* 3. Student Gender Identity

Male

Female

Non-binary

Prefer to self-describe (please specify)

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* 4. Date of Birth

Date

Date

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* 5. Address

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* 6. Student information

Grade Level

School Year

School Last Attended

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* 7. Primary Parent/Guardian Name

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* 8. Primary Parent/Guardian Phone

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* 9. Primary Parent/Guardian Email

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* 10. Primary Parent/Guardian Occupation

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* 11. Secondary Parent/Guardian Name

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* 12. Secondary Parent/Guardian Phone

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* 13. Secondary Parent/Guardian Email

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* 14. Secondary Parent/Guardian Occupation

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* 15. Emergency Contact Name

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* 16. Emergency Contact Phone

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* 17. Does your student have any allergies?

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* 18. Is your student taking any medications?

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* 19. Does your student have any medical conditions?