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Student Name

Grade completed by June 2022 (MUST BE Grades 8th-12th only) enter grade number only)

Date of Birth

Parent/Guardian Contact Phone Number

Parent/Guardian Contact Email

Mailing Address (Please type out full address in the box below. If left blank, we will not be able to send out required documents)

Parent/Guardian Name: If this student is accepted, I grant them permission to atttend.

Relationship to student

If a scholorship is requested for this student, please type "Yes"

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