Academy Advisors
REFERRAL INFORMATION
How did you hear about us?
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Church/Temple
Drive/Walk By
Groupon
Online ad
Other
Referral
Returning Student
Website
Referral Name
FAMILY INFORMATION
Family Name
Home Address
City
State
Zip
Home or Primary Phone
Emergency Contact Info (Not Contact #1 or #2)
CONTACTS
CONTACTS
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Contact First Name
Contact Last Name
Type
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Accts (Agency Billing)
Father
Grand Parent
Guardian
Main Contact
Mother
Other
Step Father
Step Mother
Work #
Cell #
Contact Email
Username for Portal Access
Password for Portal Access
Confirm Password
STUDENTS
STUDENTS
Add more Students
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Attach Profile Image
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First Name
Last Name
Student Username for Portal Access
Email
Password for Portal Access
Confirm Password for Portal Access
Birth Date
Gender
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Male
Female
Other
Prefer not to say
Special Needs
Allergies
Health Insurance Carrier
Grade
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K
1
2
3
4
5
6
7
8
9
10
11
12
College 1st Year
College 2nd Year
College 3rd Year
College 4th Year
Post-Graduate
Early Career
School
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