Homeschool Registration Form

Student Information

Full Name

Date of Birth

Month

Day

Year

Student Age (as of today)

Student Age (as of September 1, 2025)

Grade Level for Upcoming Year

Gender

Male

Female

Other

Parent/Guardian Information

Name(s)

Multi-line address

Country/Region

Address

City

Zip / Postal code

Phone Number

Email Address

Educational Background

Previous School (if applicable)

Reason for Homeschooling

Medical Information

Does the student have any allergies or medical conditions?

Yes

If yes, please specify

Emergency Contact (other than parent/guardian)

Name

Relationship

Phone Number

Curriculum and Learning Preferences

Preferred Curriculum or Program (if any)

Special Educational Needs (if any)

Parent/Guardian Certification

I certify that I am the legal parent or guardian of the student named above and that the information provided is accurate to the best of my knowledge.

Signature

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Date

Month

Day

Year