Phoenix Community Learning Center

SCHOOL CLOSED FRIDAY FEB. 1 DUE TO WEATHER

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Today's Date

STUDENT INFORMATION

Student Last Name*

Student First Name*

Student Middle Name

Birthdate*

Gender*

Male

Female

Race/Ethnic Code:

Black

White

Hispanic

Asian

Multiracial

Other:

Student's Previous School*

Parent/Guardian Name*

Select One:*

Mother

Father

Grandparent

Foster Parent

Guardian

Other:

Address*

Apartment Number

City*

State*

Zip Code*

Home Phone*

Cell Phone

PARENT INFORMATION #2

Select One:*

Mother

Father

Grandparent

Foster Parent

Guardian

Other

Parent/Guardian Name*

Parent/Guardian Address*

Parent/Guardian City*

Parent/Guardian State*

Parent/Guardian Zip Code*

Work Phone*

Parent/Guardian Email Address

What language is spoken most often by the student?*

What language is spoken most often by the parent/guardian?*

Emergency Contact #1 Name*

Emergency Contact #1 Address*

Emergency Contact#1 Phone*

Emergency Contact #2 Name*

Emergency Contact #2 Address*

Emergency Contact #2 Phone*

*Registration only. Full enrollment requires a parent interview and completing an enrollment form with all necessary documents (i.e. birth certificate, proof of residence, photo i.d., etc.).

Please submit this form and we will contact you to complete the enrollment process. Thank you!

Phoenix Community Learning Center

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Student Enrollment