Student Name

First Name

Last Name

Student Street Address

Student City

Student Zip Code

Date of Birth

YYYY

Grade for 2023-2024 School Year

Student Gender

Does the student have any physical or mental limitations?

Yes

If so, elaborate:

Previous School Attended:

Has the student ever been suspended or expelled?

Yes

If so, please explain:

Parent/Guardian Name #1

First Name

Last Name

Parent/Guardian #1 Phone

(###)

###

####

Parent/Guardian #1 Email

Parent/Guardian #2 Name

First Name

Last Name

Parent/Guardian #2 Phone

(###)

###

####

Parent/Guardian #2 Email

For application interview preference:

Morning

Afternoon

Please tell us about why you are choosing Clubhouse Academy:

Please note: All applicants will need to bring a copy of previous school transcripts and report card to your scheduled consultation. Enrollment fee will not be due until after your consultation appointment and academy enrollment is confirmed.