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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:

*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:

Parent/Guardian #1

*First Name:

*Last Name:

*Email Address:

*Cell Phone:

*Home Phone:

Parent/Guardian #2 (optional)

First Name:

Last Name:

Email Address:

Cell Phone:

Home Phone:

Child's Health Information

Medications:

Allergies:

*Physician's Name:

*Physician'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: