Street Address

City, State, Zip

Phone Number

Self-Directed Education that Empowers and Liberates

Your Custom Text Here

Student and Caregiver Information

The contact information is intended to appear in the Heartwood Family Directory.

Today's Date

YYYY

Student's First and Last Name

First Name

Last Name

What is your student's preferred name?

What would your student like to be called

What are your student's pronoun(s)?

Student's Date of Birth

YYYY

In what school district does the student reside?

We will need to enroll your Student into your School District. (i.e. - Atlanta Public Schools, Dekalb County Schools, Decatur City Schools, etc.)

CAREGIVER(S) INFORMATION

Caregiver #1 First and Last Name

First Name

Last Name

Caregiver #1 Pronouns

Caregiver #1 Email

example@example.com

Caregiver #1 Phone Number

(###)

###

####

Caregiver #1 Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Caregiver #2 First and Last Name

If applicable

First Name

Last Name

Caregiver #2 Pronouns

Caregiver #2 Email

example@example.com

Parent/Guardian #2 Phone Number

(###)

###

####

Caregiver #2 Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

EMERGENCY CONTACT INFORMATION

Emergency Contact #1

In addition to the named Caregiver(s) above

First Name

Last Name

Emergency Contact #1 Phone Number

(###)

###

####

Emergency Contact #1 Relationship to Student

Emergency Contact #2

In addition to the named Caregiver(s) above

First Name

Last Name

Emergency Contact #2 Phone Number

(###)

###

####

Emergency Contact #2 Relationship to Student

Physician's Name

First Name

Last Name

Physician/Clinic Phone Number

(###)

###

####

Physician/Clinic Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Our application has several pages, so please remain in your browser window after clicking “SUBMIT” on this and each page following. Your last page of the application will be submitting a tuition offer. We look forward to learning more about you!