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Northwest Missouri State University


Application for Enrollment (New Student)

Please note: If you do not receive a confirmation email regarding your child's application within one month, please contact the office.

* indicates required fields

Child Information
Student (919) ID: (if known)
* First Name:
* Last Name:
* Birthdate: (format: MM/DD/YYYY)
* Gender: Female     Male
* Enrollment Status:   (for office use only)
* Homeroom:   (for office use only)
Home Address
* Street 1:
Street 2:
* City:
* State:
* ZIP Code:
* Country:
1. Parent/Guardian 2. Parent/Guardian
* First Name: First Name:
* Last Name: Last Name:
* Email Address: Email Address:
* Cell Phone: Cell Phone:
* Home Phone: Home Phone:
Child's Health Information
Medications:
Allergies:
* Physican's Name:
* Physican's Phone:

I understand that this application does not constitute actual enrollment in the Early Childhood Center. I realize that actual enrollment in the school is governed by limitations of class size and by priorities established by the Board of Regents of the University. I understand that my child’s name will be placed on a waiting list.
Yes     No

I attest that my child is not currently suspended or expelled from any public district or private school in the United States.
Yes     No

* Legal Signature of Parent/Guardian: