HIGH SCHOOL PROGRAM APPLICATION

Name *

First Name

Last Name

Gender* *

Male

Female

Date of Birth *

MM

DD

YYYY

Has your child attended East Harlem Tutorial Program before? *

Yes

No

Primary language spoken at home: *

Yes

No

Are you applying for another child in the family?

If yes, please complete below for each sibling. If no, please continue to the next section.

Yes

No

Name *

First Name

Last Name

Lives with scholar?

Yes

No

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Phone Type *

Work

Home

Cell

Name

First Name

Last Name

Lives with scholar?

Yes

No

Primary Phone Type

Work

Home

Cell

Does your child have an IEP? *

Yes

No