Enrollment Request Short Form

Parent/Guardian First and Last Name (*)
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Child's First and Last Name (*)
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Grade (You are interested in) (*)
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Address and Zip Code (*)
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Telephone Number
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Alternate Number
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Email Address
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Child's Age
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Date of Birth: Month (*)
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Date of Birth: Day (*)
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Date of Birth: Year (*)
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School Year Interested In
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Today's Date
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I acknowledge and understand that the information on this form will be used solely for communications related to the Harambee Institute of Science and Technology Charter School (HISTCS) enrollment process. Submitting this form does not indicate nor confirm acceptance of my student into HISTCS. (*)
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