*First Name: Middle Name: *Last Name:
*Birth Date (MM/DD/YYYY): Age: Sex: Male Female

*Grade 2008-2009: *Last School Attended: Child's Religion:
*Child Resides With:

*Address: *City: *State: *Zip Code:
*Home Phone (including area code): Child's Race:

Mother's First Name: Mother's Last Name:
Marital Status: Single Married Separated Divorced Widowed

If same as the STUDENT'S information above, check here . If changes are made above, uncheck and re-check box .
Street Address: City: State: Zip Code:
Home Phone (including area code):

Mother's Cell Phone (including area code)#: email:

Mother's Occupation:
Employer or Business Name: Employer Phone # (including area code):

Father's First Name: Father's Last Name:
Marital Status: Single Married Separated Divorced Widowed

If same as the STUDENT'S information above, check here . If changes are made above, uncheck and re-check box .
Street Address: City: State: Zip Code:
Home Phone (including area code):

Father's Cell Phone # (including area code): email:

Father's Occupation:
Employer or Business Name: Employer Phone # (including area code):

Step Mother's Full Name (if applicable):
Step Father's Full Name (if applicable):

Registration fees are $125.00 per student. All registration fees are non-refundable.

List any chronic illnesses, allergies, or medications:

*Doctor's Name: *Doctor's Phone Number (including area code):

*Emergency Contact Person (someone outside the home):
*Relation to Child:
*Phone Number (including area code):

I give my permission for my child to use the Internet while at eLearningK12. I understand that all reasonable measures will be taken to insure my child will not access inappropriate material while at eLearningK12 facilities. I also recognize it is impossible to restrict access to all inappropriate materials, and I will not hold eLearningK12 or its agents responsible for material accessed on the network. I accept full responsibility for supervision when my child's Internet use is not at an eLearningk12 center.

I give permission for eLearningk12 staff to publish my child's pictures on the school web site at their discretion. I understand my child's last name will never be disclosed on the web site without my permission.

I authorize a representative of eLearningK12 to transport my child and obtain any medical attention should the need arise.

* I agree to the terms above.

*Location: --Please Select One-- Donaldsonville Elite Academy Houma Thibodaux--North Canal Thibodaux--St Mary Not Sure

*Curriculum Level: (6th - 8th graders have a choice of the elementary or high school curriculum.)
Please Select One Elementary( K-8) Junior High (6-8) High School (9-12) If Junior High is chosen, there will be $500 added to the Elementary tuition.

*Preferred Number of Days: Please Select One Virtual Home School 1 Day per week 2 Days per week 3 Days per week 4 Days per week 5 Days per week

Please indicate your preference of days (if applicable): Monday Tuesday Wednesday Thursday Friday

Select a time Preference: 8:00 to 12:00 12:30 to 4:30 12:30 to 3:30 12:30 to 2:30 Not Applicable

New this Year: Extend your child's day with Enrichment Activities! We will be offering a variety of
enrichment classes from 12:30 to 3:30 for those of you who wish to extend your child's day. Activities such as art,
drama, music, tennis, foreign language, creative writing, violin, etc., will be offered at this time. Extended
hours may be scheduled now or later.

Please check the boxes below that interest you:

Comments or Requests:

How are you planning to pay for tuition? Prepay or Finance Both

*Email Registration Confirmation to:

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