Student Name *

First Name

Last Name

Student Birthday *

MM

DD

YYYY

Gender *

Male

Female

I am enrolling my child in the following program(s): *

(Check all that apply)

Basic Math

US Geography

Culinary Tour of the USA

Language Lab (Upper Elementary/Middle School)

Language Lab (High School)

Writing Essentials (Upper Elementary/Middle School)

Writing Essentials (High School)

Biology with Lab

Geometry

Foundations of Algebra

Private Tutoring

Lego Club

Primary Parent Name/Legal Guardian #1 *

First Name

Last Name

Relation to Student *

Father

Mother

Guardian

Stepfather

Stepmother

Grandparent

Other

Primary Phone #1 *

(###)

###

####

Primary Parent Name/Legal Guardian #2

First Name

Last Name

Relation to Student

Father

Mother

Guardian

Stepfather

Stepmother

Grandparent

Other

Primary Phone #2

(###)

###

####

Primary Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Secondary Household Parent #1

First Name

Last Name

Relation to Student

Father

Mother

Guardian

Stepfather

Stepmother

Grandparent

Other

Secondary Household Parent Phone #1

(###)

###

####

Secondary Household Parent #2

First Name

Last Name

Relation to Student

Father

Mother

Guardian

Stepfather

Stepmother

Grandparent

Other

Secondary Household Parent Phone #2

(###)

###

####

Secondary Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Do you have any homeschooling experience? *

This is all new, I have never homeschooled

1-2 years

3-4 years

I am a pro and have been homeschooling for years

I agree to allow my child’s name and photograph to be included in Cedar Hill Academy publications and in information shared with the media and\or social media accounts. *

Yes

No

Does your child have any food or environmental allergies? *

Yes

No