Application

Date: *
Mother's Name: *
Father's Name:
Address: *
Are you a resident of one of these counties: Anson, Richmond, Chesterfield, Marlboro? *	Yes No
*E-mail address:
Home Phone: xxx-xxx-xxxx *
Father's Cell Phone or Work: xxx-xxx-xxxx
Mother's Cell Phone or Work: xxx-xxx-xxxx
Emergency Contact:
Emergency Contact Phone: xxx-xxx-xxxx
Emergency Contact Relationship to Child(ren):
Years Homeschooling:
Father Special Interest/ Talents:
Mother Special Interests/ Talents:
Child #1 - Name: *
Child #1 - Male or Female:
Child #1 - Birth Date:
Child #1 - Grade (split grades acceptable) *
Child #1 - Allergies:
Child #1 - Hobbies/ Special Interests:
Child #2 - Name:
Child #2 - Male or Female:
Child #2 - Birth Date:
Child #2 - Grade (split grades acceptable)
Child #2 - Allergies:
Child #2 - Hobbies/ Special Interests:
Child #3 - Name:
Child #3 - Male or Female:
Child #3 - Birth Date:
Child #3 - Grade (split grades acceptable)
Child #3 - Allergies:
Child #3 - Hobbies/ Special Interests:
Child #4 - Name:
Child #4 - Male or Female:
Child #4 - Birth Date:
Child #4 - Grade (split grades acceptable)
Child #4 - Allergies:
Child #4 - Hobbies/ Special Interests:
Child #5 - Name:
Child #5 - Male or Female:
Child #5 - Birth Date:
Child #5 - Grade (split grades acceptable)
Child #5 - Allergies:
Child #5 - Hobbies/ Special Interests:
Child #6 - Name:
Child #6 - Male or Female:
Child #6 - Birth Date:
Child #6 - Grade (split grades acceptable)
Child #6 - Allergies:
Child #6 - Hobbies/ Special Interests:
Confirm form validation code: