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Registration form

Parent/Guardian Information

Name

Relationship to student(s)

Phone

Emergency Contact Name

Emergency Contact Relationship to student(s)

Emergency Phone

Home Address

Does any member of your household receives Supplemental Nutrition Assistance Program (SNAP) (formerly food stamps) or Ohio Works First (OWF) benefits?

Yes No

Home District Information

Do you feel your home district (local public school) provided the program necessary to meet your child’s academic and social needs, and in an environment that you felt was safe?

Yes No Not Applicable

Why did you choose to leave your home district (local public school)?