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Application Form:

Complete and submit the following application form to apply to our school. If you need help, please contact the office at 985-447-5994 or email us at [email protected]

Student Information

First Name *

Last Name *

Middle Name *

Preferred Name

Date of Birth *

Most Recent School *

Grade Level *

Gender *

Level *

Academic Year *

Street *

City *

State *

ZIP *

Country *

Parish or County *

Race *

Hispanic *

Notes

Primary Parent/Guardian Information (With Whom the Student Resides)

Relationship *

First Name *

Last Name *

Email *

Phone *

Secondary Phone *

Is this person allowed to pick up the student? *

Does this person have legal custody of the student? *

Alternate Parent/Guardian Information

Relationship

First Name

Last Name

Phone

Secondary Phone

Is this person allowed to pick up the student?

Does this person have legal custody of the student?

Payment Information

Name on Card *

Card Number *

Security Code *

Expiration Date *

Payment Address

Use the same of Student Information

Street *

City *

State *

ZIP *

Country *

Parish or County *

Level 3 Onsite Information (For Level 3 Only)

Location

How many days a week the student will attend?

How many hours per day will the student attend?

Will the student attend AM or PM?

SSN

Medical Issues *

Please describe the medical issue if applicable

Louisiana Secure Student ID

Graduation Path

Does the student have special needs, Special Ed IEP, 504, Gifted? *

Emergency Contact Information (For Level 3 Only)

Relationship *

First Name *

Last Name *

Email *

Phone *

Secondary Phone *

Is this person allowed to pick up the student?

Does this person have legal custody of the student?

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