STUDENT APPLICATION FORM 26/27

Student Application Form

There is a $225 application fee per child. This is nonrefundable.
Primary Guardian's First and Last Name*

First NameLast Name
Primary Guardian's Email Address*
example@example.com
Primary Guardian's Phone Number*
Please enter a valid phone number.
Secondary Guardian's First and Last Name

First NameLast Name
Secondary Guardian's Email Address
example@example.com
Secondary Guardian's Phone Number
Please enter a valid phone number.
Primary Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
STUDENT INFORMATION
How many children are you applying for?*

OneTwoThreeFour
Student #1 Name*

First NameLast Name
Student #1 Entering Grade Level*
Student #2 Name

First NameLast Name
Student #2 Entering Grade Level
Student #3 Name

First NameLast Name
Student #3 Entering Grade Level
Student #4 Name

First NameLast Name
Student #4 Entering Grade Level
EXTRACURRICULARS
Are you interested in enrolling your child(s) in Extracurriculars from Monday-Thursday from 1:15-3:00 for $600/quarter?*

YesNo
Are you interested in enrolling your child(s) in Before-School Care from Monday-Thursday from 7:40-8:40 for $500/child per quarter?*

YesNo
Are you interested in enrolling your child(s) in After-School Care from Monday-Thursday from 3:00-4:00 for $500/child per quarter?*

YesNo
Are you interested in enrolling your child in optional Fridays from 9:00-1:00 ONLY for $1,200 a year? (This day will be supervised by our licensed teachers to aid in your child(s) completion of Friday’s work and our Growth Factor business curriculum).*

YesNo
ABOUT YOUR CHILD(S)
What type of school are you currently enrolled in?*
In order to best serve your child, has your child(s) ever had an IEP, 504 or receive any outside services? If so, please explain.*
Tell us a little about your interest, expectations, and hopes for your child(s)’ school year. *
PAYMENT
How would you prefer to make tuition payments for the school year?*

My Products*

Application FeeThe Application Fee is $225 per child. Your child(s) will not be added to the official waitlist unless an application fee has been submitted for each kid. Please choose the number of children you are applying for to correctly calculate the Application Fee.

$225.00 Quantity

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

I, First Name* Last Name* , understand that I am applying for my child(s) to be enrolled for the 2026-2027 Haven Academy school year by completing and submitting this form. I understand that the $225 application fee per child(s) is non-refundable.
Guardian Signature*

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Student Application Form