Student Enrollment Form
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3STUDENT ENROLLMENT FORM
Student Information
Name
Sex
Nickname (if any)
Date of Birth
Age
Program Site
Start Date
15-16 School Grade
Home Address
City
Zip
Parent/Legal Guardian w/ Whom Student Lives
List only individuals who have legal custody of child. If both parents are not listed, or if guardian is not a parent, legal proof of custody must be provided.
st
Name
Home Address
Home Phone
Relationship to Student
City
Zip
Cell Phone
Email Address
Place of Employment
Work Phone
Name
Home Address
Home Phone
Relationship to Student
City
Zip
Cell Phone
Email Addres:
Place of Employment
Work Phone
Parent/Legal Guardian Not Living w/ Student
Home Address
Work Phone
Name
Relationship to Student
City
Zip
Cell Phone
Email Address:
Place of Employment
Home Address
Work Phone
Name
Relationship to Student
City
Zip
Cell Phone
Email Address
Place of Employment
Emergency Contacts (other than above) minimum of 2 required
Name
Home Address
Work Phone
Relationship to Student
City
Zip
Cell Phone
Name
Home Address
Work Phone
Relationship to Student
City
Zip
Cell Phone
Authorized Pickup
Name
Home Address
Work Phone
Relationship to Student
City
Zip
Cell Phone
Legal documentation must be provided to AlphaBEST Regarding any custodial evidence or authority limitations of either parent or guardians.
Without legal documentation to the program attended by the child, either parent will be allowed full access to the child at all times program
operation.
Date
Parent Signature
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