Student Application Parent / Legal Guardian 1's Name * First Name Last Name Parent / Legal Guardian 2's Name ( If Applicable ) First Name Last Name Email * Phone Number * (###) ### #### Student's Name * First Name Last Name Student's Date of Birth * MM DD YYYY Has the Student Been Diagnosed With Autism? * No Yes Have you applied for the Empowerment Scholarship Account (ESA)? * No Yes Prior School Student Attended? (If Any) Thank you!We Will Reach Out To You As Soon As Possible!
