Parent First Name
*
Parent Last Name
*
Phone
*
Email
*
Student First Name
*
Student Last Name
*
Grade Applying For 2026–2027
*
Student Date of Birth
*
Previous School
*
Program Interest
Regular School
SPORTS
STEM AI
Summer
Foster Care
Unknown
Preferred Shift
*
Student has an IEP?
*
Student has a 504 Plan?
*
Foster Care / Shelter-In-Place?
*
DCF/CBC Placement Letter or Notice of Case Action Upload
*
PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF
Scholarship Status / Interest
*
Interested
Applied
Awarded
Needs to Apply
Not Applicable
Scholarship Program
*
Payment Path
*
Household Income Range
*
Student Allergies / Medical Notes
Previous Psychological Testing
Yes
No
Unknown
Health Insurance Carrier
Health Insurance Type
Health Insurance Policy Number
Emergency Contact Name
*
Please provide someone we can contact if we are unable to reach the parent or legal guardian.
Emergency Contact Phone
*
Emergency Contact Relationship
*
Authorized Pickup Notes
Parent / Guardian Signature
Clear
Submit