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MISSOURI Demo Site

Administration
Enrollment Form

Enrollment Form

Please fill out the form below

Enrollment Form

Please Fill Out The Enrollment Form Below

Reaquired field: Child's Legal First Name
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Reaquired field: Name
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Child's Middle Name
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Reaquired field: Child's Legal Last Name
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Child's Preferred Name
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Reaquired field: Home Street Address
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Apt. #
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Reaquired field: City
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Reaquired field: Zip Code
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Gender

Female

Male

Reaquired field: Date of Birth:

Reaquired field: Grade Entering
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Special Education:

No

Yes

504 Plan:

No

Yes

U.S. Citizen:

No

Yes

ESL:

No

Yes

If Yes, what is the Native Language:
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Ethnic Group:

White

Black

Hispanic

Asian

Native American

Multi-Racial

Prefer Not To Answer

Other
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Reaquired field: Last School Attended:

Reaquired field: Date Last Attended:

Reaquired field: Last Grade Completed:
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Student resides with:

Both Parents

Mother

Father

Other

Other

If Other, Name and Relationship:
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Legal/Custody Papers?

No

Yes

Mother's First Name
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Mother's Last Name
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Mother's Home Phone Number
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Mother's Street Address
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Mother's City of Residence
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Mother's Cell Phone
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Reaquired field: Work Phone

Mother's Place of Employment
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Mother's Work Phone
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Father's First Name
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Father's Last Name
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Father's Home Phone Number
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Father's Street Address
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Father's City of Residence
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Father's Cell Phone
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Father's Place of Employment
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Father's Work Phone
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Guardian's First Name
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Guardian's Last Name
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Guardian's Home Phone Number
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Guardian's Street Address
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Guardian's City of Residence
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Guardian's Cell Phone
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Guardian's Place of Employment
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Guardian's Work Phone
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Reaquired field: Emergency Contact (First Name):
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Reaquired field: Emergency Contact (Last Name):
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Reaquired field: Emergency Contact (Phone Number):
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Reaquired field: Relationship to Child:
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Reaquired field: Emergency Contact (First Name):
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Reaquired field: Emergency Contact (Last Name):
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Reaquired field: Emergency Contact (Phone Number):
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Reaquired field: Relationship to Child:
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Email a copy to

optional

Required Fields

Missouri Demo Site

555 Street Name, City, State 77777
Phone: 555-555-5555

Log In

Missouri Demo Site

555 Street Name, City, State 77777
Phone: 555-555-5555

Log In

Log In

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