Scholar’s name:          Birth date:  //

Home address:         Race:   Select African American American Indian Asian Caucasian Hispanic

City:       Zip code:  

Scholar’s current school:  

Select term for admittance consideration: If later than fall of 2012 please use our preregistration enrollment option:   Select Fall of 2012

Grade level for admittance term:   Select 8th 9th 10th 11th 12th |

Mathematics course will your scholar complete this year:   Select 8th Grade Math Pre-Algebra Algebra Geometry Algebra II Trigonometry Algebra III Finite Mathematics AP Calculus AB AP Calculus BC AP Statistics

Has applicant been expelled from another school?    Select Yes No

If yes, which one?  

Has applicant ever skipped a grade?    Select Yes No

Has applicant ever repeated a grade?    Select Yes No

Applying parent/Legal guardian name:  

Home# ()  Cell# ()  Ex: 1234567 (No spaces; No dashes)

Valid e-mail address:  

If Applicable:
Spouse/Legal guardian name:  

Valid e-mail address:  

By submitting this application, I affirm to the best of my knowledge all information contained herein is complete and accurate.  I fully understand any false information, omissions or misrepresentations of facts may result in rejection of this application and/or future dismissal of the applicant.

Nota Bene:  All scholars must provide hard copies of their immunization records, social security card, birth certificate and academic transcripts to Haas Hall Academy before they will be allowed to attend classes.

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