Enrollment Form - Permission to Succeed
Student's First Name
*
Student's Last Name
*
Student Date of Birth
*
Allergies
*
Medication
*
Address Line
*
Address line 2
City
*
State
*
Zipcode
*
Country
*
Current Grade
*
What grade are you in NOW
Last school attended
*
Step Up for Students AWARD ID
Upload Birth Certificate
PDF, JPG, PNG, GIF, or WEBP · up to 25 MB
Upload Immunization or Waiver
PDF, JPG, PNG, GIF, or WEBP · up to 25 MB
Upload Physical
PDF, JPG, PNG, GIF, or WEBP · up to 25 MB
Which Program Are You Interested In?
*
I.E.P.
PDF, JPG, PNG, GIF, or WEBP · up to 25 MB
Last Report Card
PDF, JPG, PNG, GIF, or WEBP · up to 25 MB
Parent/Guardian First Name
*
Parent/Guardian Last Name
*
Parent/Guardian Email
*
Parent/Guardian Mobile Phone
*
If you would like to add another parent, you can do so by typing it in here:
First Name
Last Name
Mobile Phone
Relation
If you would like to add an additional authorized pick up person, you can do so by typing it in here:
Liability Waiver: I've read the above and agree
*
Photo Release: I've read the above and agree
*
Cancellation and Refunds: I've read the above and agree
*
Submit