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Copy of Application Submitted Students Name: Date of Birth: Parents Name: Address: City, State Zip: , E-mail Address: Phone: Alternate Phone: Student Gender: Student Ethnicity: Student has book Young People Ask?: I have: For High School: Previous High School: Address: City: State/ZIP: Fax No.:
Desired Math: Elective #1: Elective #2: Elective #3: Elective #4: Additional Fees: Foreign Languages CDs: Hands-on Art Electives: Total of Additional Fees: Check or Money Order Mailed: MasterCard/Visa No: CCV: Expiration Date: Name on Card: Amount to Charge: Agreement Name: Book Fee The undersigned hereby authorizes
Pearblossom Academy, Inc. to obtain a release of student information, including transcripts, from previously attended schools. Signature: Date: