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Founder's Message
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Mission & Vision
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Core Values
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Organization Structure
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ELOM Q&A
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Employment Opportunities
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Related Links
Enrollment Application.
The fields with an asterisk are required.
Student Information
Entering Grade: *
First Name: *
Last Name: *
Middle Initial:
Sex:
Male
Female
Address
Apt/Unit #:
City:
State:
ZIP Code: *
Phone Number: *
Birth Date: (mm/dd/yy) *
Home Language:
Email: (if available) *
Ethnicity: (optional)
Alaskan Native
American Indian
Asian/Pacific Islander
African American
Caucasian
Chicano/Mexican American
Hispanic
Puerto Rican
Other
Student Lives With:
Parent(s)
Guardian
Foster Care
Other
Name/Age/Grade of all children in the family under the age of 21:
Does you child have a disability? If yes explain:
No
Yes
Does your child currently have a 504 plan?
No
Yes
Has your child ever been identified for Special Education services?
No
Yes
Does your child currently have a Special Education IEP?
No
Yes
Has your child ever been expelled from school?
No
Yes
Parent Information: Mother/Guardian
Name: *
Home Phone: *
Work Phone: *
Address
City:
State:
ZIP Code:
Email: (if available) *
Place of employment:
Employer's Address:
Parent Information: Father/Guardian
Name: *
Home Phone: *
Work Phone: *
Address:
City:
State:
ZIP Code:
Email: (if available) *
Place of employment:
Employer's Address:
