Student Name *

First Name

Last Name

Sex *

Male

Female

Birth Date *

MM

DD

YYYY

Ethnicity *

African American

Latino

White

Asian

Other

West A Member? *

Yes

No

Do you authorize your student to take public transit or rideshares? *

Yes

No

Class Year (High school graduation year) *

College

2025

2026

2027

2028

2029

2030

2031

(GUARDIAN # 1) *

First Name

Last Name

Relationship to Student *

Father

Mother

Grandparent

Other Relative

Family Friend

Legal Custodian

Cell Number *

(###)

###

####

Home Number

(###)

###

####

Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Full Name (GUARDIAN # 2)

If I am unavailable, I give permission to release my child to this person and to contact them in case of an emergency.

First Name

Last Name

Phone Number (GUARDIAN # 2)

(###)

###

####

Relationship to Student (GUARDIAN # 2) *

Father

Mother

Grandparent

Other Relative

Family Friend

Legal Custodian

Which classes would your student like to enroll in? *

(Select all that apply)

Foundational Math

Algebra

Advanced Algebra

Geometry

Adv. Math Pre-Calculus

Calculus