Student Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

What grade level for the 2025-26 school year?

10th

11th

12th

Do you have an active IEP/504 plan?

Yes

No

Are you or have you ever been homeschooled?

Yes

No

Would you be eligible for free lunches?

Eligibility varies - Examples: SNAP qualifies OR a family of four with a household income of $55,000 or less qualifies.

Yes

No

Parent / Guardian Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Please keep me posted with updates about CSA-Xenia!

Yes

No