Student’s Name *

First Name

Last Name

Parent or Guardian Name *

First Name

Last Name

Cell Phone *

(###)

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Home Phone

(###)

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Will you be using charter funding to pay tuition? *

No

Yes - Clarksville

Yes - Cottonwood

Photo Consent *

Do you consent to have student's photo posted on social media and marketing tools?

Yes

No

If you answered "Yes" above:

Check all boxes that apply to what type of photos you consent to being posted on social media and marketing tools.

Hands

Face

Full body

Emergency Contact *

If we are unable to reach you in the event of an emergency or if the student is left without transportation, who would you like us to contact?

First Name

Last Name

Phone number of Emergency Contact *

(###)

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