Student Enrollment

Please complete the form below. Required fields marked *

Today's Date

Answer Required

STUDENT INFORMATION

Student Last Name*

Answer Required

Student First Name*

Answer Required

Student Middle Name

Answer Required

Entering Grade*

Answer Required

Birthdate*

Answer Required

Gender*

Answer Required

Male

Female

Race/Ethnic Code:

Answer Required

Black

White

Hispanic

Asian

Multiracial

Other:

Student's Previous School*

Answer Required

Parent/Guardian Name*

Answer Required

Select One:*

Answer Required

Mother

Father

Grandparent

Foster Parent

Guardian

Other:

Address*

Answer Required

Apartment Number

Answer Required

City*

Answer Required

State*

Answer Required

Zip Code*

Answer Required

Home Phone*

Answer Required

Cell Phone

Answer Required

PARENT INFORMATION #2

Select One:*

Answer Required

Mother

Father

Grandparent

Foster Parent

Guardian

Other

Parent/Guardian Name*

Answer Required

Parent/Guardian Address*

Answer Required

Parent/Guardian City*

Answer Required

Parent/Guardian State*

Answer Required

Parent/Guardian Zip Code*

Answer Required

Work Phone*

Answer Required

Parent/Guardian Email Address

Answer Required

What language is spoken most often by the student?*

Answer Required

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

Answer Required

Emergency Contact #1 Name*

Answer Required

Emergency Contact #1 Address*

Answer Required

Emergency Contact#1 Phone*

Answer Required

Emergency Contact #2 Name*

Answer Required

Emergency Contact #2 Address*

Answer Required

Emergency Contact #2 Phone*

Answer Required

*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

Please fix the highlighted areas below before submitting.

Student Enrollment