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Parent / Guardian Information
First Parent / Guardian Last Name * First Name * Middle Name Salutation Email Address * Gender Male Female Work Phone (Ex: 999-999-9999) Cell Phone (Ex: 999-999-9999)	Second Parent / Guardian (leave blank if not applicable) Last Name * First Name * Middle Name Salutation Email Address * Gender Male Female Work Phone (Ex: 999-999-9999) Cell Phone (Ex: 999-999-9999)

Home Address
Street Address City Country State Zip Home Phone (Ex: 999-999-9999) How Did You Hear About Us? * Details: Student 1 First Name * Middle Name Last Name * Birthdate (mm/dd/yyyy) Email Address Gender Male Female Grade Level of Interest * School Year * Current School Which program are you interested in? * School Year Academic Program Summer Academic Program English as a Second Language Summer Lancer Day Camp Summer Adventure Camp Summer Raider School Are you interested in visiting the Academy? Attend an Open House Schedule a visit Receive information via mail Is There Another Student? Yes No Parent / Guardian Notes