Registration

Registration

Registration Form

Child's First Name:

Child's Last Name:

Date of Birth:

Child's Age:

Gender:

Current Grade Level:

School Type:

School Name:

County/District

Brief description of concerns:

Exceptional Student Education

Retained (Repeated) Past Grade:

Parent's First Name:

Parent's Last Name:

Home Address:

City/State

Zip Code

Contact Number:

Best Time to call:

Email Address:

Emergency Contact Name

Emergency Contact Number:

Student's Accomplishments:

English for Speakers of other Language

Zelle payment to:www.smartexplorers411@gmail.com

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