Enroll at The Genesis School| Grades PreK-8 Free Enrollment

How did you hear about us?

Student Information

Student First Name

Student Middle Name

Student Last Name

Gender

Male
Female

Birthdate

Grade student will be entering

Student Home Address

Address Line 1

Address Line 2

City

State

Zip Code

Birthplace City

Birthplace State

Resident School District

Is this student Hispanic/Latino

Not Hispanic/Latino
Hispanic/Latino

Is this student multi-racial?

Not multi-racial
Multi-racial

Ethnicity (check all that apply)

this Mother Mother

Does the student have an IEP?

Yes
No

If yes, indicate the date the IEP was signed:

Mother Information

Mother Residence

Residential
Non-residential

Mother Last Name

Mother First Name

Mother Maiden Name

Mother Address

Address Line 1

Address Line 2

City

State

Zip Code

Mother Email

Mother Home Phone

Mother Work Phone

Mother Mobile Phone

Father Information

Father Residence

Residential
Non-residential

Father Last Name

Father First Name

Father Address

Address Line 1

Address Line 2

City

State

Zip Code

Father Email

Father Home Phone

Father Work Phone

Father Mobile Phone

Custodial Guardian Information

Is the person registering the student the custodial guardian?

Yes
No

Custodial Guardian Address

Address Line 1

Address Line 2

City

State

Zip Code

Custodial Guardian Email

Emergency Contact Information

The Genesis School requires two emergency contacts.

Emergency Contact #1

Contact #1 Last Name

Contact #1 First Name

Contact #1 Relationship to Student

Contact #1 Home Phone

Contact #1 Work Phone

Contact #1 Mobile Phone

Contact #1 Address

Address Line 1

Address Line 2

City

State

Zip Code

Emergency Contact #2

Contact #2 Last Name

Contact #2 First Name

Contact #2 Relationship to Student

Contact #2 Home Phone

Contact #2 Work Phone

Contact #2 Mobile Phone

Contact #2 Address

Address Line 1

Address Line 2

City

State

Zip Code

Media Release Authorization

By completing this enrollment form, you are granting permission for The Genesis School to use your child's photograph, voice, and/or name in school-related media. This includes video and audio recordings, films, photographs, and written articles published in school communications, on our website, and shared with news outlets such as newspapers, radio, and television stations. If you do NOT wish to grant this permission, please check the box below. If left unchecked, your signature on this enrollment form serves as your consent to the media release terms above.

Opt out of the media release

I do not give The Genesis School permission to use my child's photograph, voice, or name in any school media.

Signature Section

Signature of Person Completing Registration

Date

Register Online

Student Information

Mother Information

Father Information

Custodial Guardian Information

Emergency Contact Information

Emergency Contact #1

Emergency Contact #2

Media Release Authorization

Signature Section