STUDENT APPLICATION FORM 26/27

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.Format: (000) 000-0000.

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.Format: (000) 000-0000.

Primary Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

STUDENT INFORMATION

How many children are you applying for?

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 $650/quarter?

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?

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?

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).

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 Fee

The 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

Debit or Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year

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

Guardian Signature

Student Application Form

My Products*

My Products