Application Form FAMILY INFORMATIONName of Applicant First Middle Last NicknameGenderMaleFemaleThis applicant is for gradefor the school yearApplicant’s ageApplicant’s birth date Date Format: MM slash DD slash YYYY Applicant’s address Street Address City State / Province / Region ZIP / Postal Code Home PhoneParent/Guardian #1Name Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last OCCUPATIONPOSITIONOFFICE PHONECELL/PAGEREmail Address Parent/Guardian #2Name Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last OCCUPATIONPOSITIONOFFICE PHONECELL/PAGERPlease check all that apply Parents married Parents separated Parents divorced Father remarried Father deceased Applicant lives with father Mother remarried Mother deceased Applicant lives with mother If applicant does not live with both parents, please provide the name and address of the parent who does live with the applicant:If applicant does not live with both parents, please provide the name and address of the parent who does live with the applicant:Name Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Address Street Address City State / Province / Region ZIP / Postal Code Home PhoneEDUCATIONSchool now attending/last attendedSCHOOL ADDRESS Street Address City State / Province / Region ZIP / Postal Code Phone NumberTeacher/Counselor who best knows the applicantPositionTEACHER’S ADDRESS (IF NOT SCHOOL ADDRESS) Street Address City State / Province / Region ZIP / Postal Code Registration Fee Price: $250.00 PARENT SIGNATUREDate Date Format: MM slash DD slash YYYY The registration fee is $250 per child payable to Imagination School, LLC, in full at the time of registration. Placement of a child on the class list is not assured until this fee is paid. This fee is non-refundable. This amount is the same no matter when a student starts the school year.Imagination School, LLC does not discriminate on the basis of race, color, gender, ethnic origin, or similar factorsImagination School, LLC does not discriminate on the basis of race, color, gender, ethnic origin, or similar factors
