Student Registration Form

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College Blueprint Student Registration Form

I am interested in: *

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* Indicates required field

Student Name *

First

Last

Date of Birth *

Format - DD/MM/YY

Current School *

GPA *

Year of Graduation *

Student Home Address *

Line 1

Line 2

City

State

Zip Code

Country

Student Email *

Student Mobile Number *

Testing

SAT *

ACT *

SAT *

ACT *

SAT *

ACT *

PSAT *

Student's Curriculum Includes (Check All That Apply) *

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Referrals are the biggest compliment we can receive. Who may we thank for referring you to us? *

Parent/Guardian Information

Parent/Guardian Name *

First

Last

Email *

Mobile Phone *

Home Phone *

Work Phone *

Parent/Guardian Home Address *

Line 1

Line 2

City

State

Zip Code

Country

Employer *

Position *

Billing

Name of Person Responsible for Billing & Payment *

First

Last

Phone Number *

Driver's License Number *

Sibling Information

Sibling #1 Name *

First

Last

Sibling #1 Date of Birth *

Format - DD/MM/YY

Sibling #1 Current Grade *

Sibling #2 Name *

First

Last

Sibling #2 Date of Birth *

Format - DD/MM/YY

Sibling #2 Current Grade *

Sibling #3 Name *

First

Last

Sibling #3 Date of Birth *

Format - DD/MM/YY

Sibling #3 Current Grade *

Help Us Get to Know You and Your Student Better

Your student's favorite activities: *

Parent/guardian's community involvment *

Your student's community involvement: *

3-6 favorite words to describe your student: *

Any medical or learning issues of which we should be aware? *

Is there anything else you think would be helpful for us to know about your student? *

Please indicate any learning differences which will help us understand your student's approach to learning: *

AD/HD (Hyperactive Type) AD/HD (Inattentive Type) Dyslexia Dysalculia Auditory Processing Disorder Visual Processing Disorder Nonverbal Learning Disorder High Functioning Autism Other*

*Please specify *

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