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2021 - 2022 SIUE East St. Louis Charter High School Application
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* Indicates required question
Email
*
Your email
Student's First Name:
*
Your answer
Student's Middle Name:
Your answer
Student's Last Name:
*
Your answer
Date of Birth:
*
Example: 01/01/2022
MM
/
DD
/
YYYY
Age:
*
Your answer
Gender:
*
Female
Male
Ethnic Group:
*
Black / African American
American Indian / Native Alaskan
Hispanic
White / Caucasian
Native Hawaiian / Pacific Islander
Asian
Other:
Student lives with:
*
Parents
Mother
Father
Guardian
Grandparent
Foster Parent
Other:
Required
Parent / Guardian -1 Name:
*
Your answer
Parent / Guardian - 1 Relationship to Student:
*
Your answer
Parent / Guardian - 2 Name:
Your answer
Parent / Guardian - 2 Relationship to Student:
Your answer
Street Address:
*
Your answer
City:
*
Your answer
State:
*
Your answer
Zip Code:
*
Your answer
Primary Telephone Number:
*
Example: 123-456-7890
Your answer
Other Telephone Number:
Example: 123-456-7890
Your answer
Parent/Guardian's Email Address:
*
Your answer
Does the student have a sibling already enrolled in this school?
Yes
No
Clear selection
If yes, what is the sibling's name?
Your answer
As of today, what grade is the student in?
*
8th
9th
10th
11th
12th
Currently In School?
*
Yes
No
What school did they last attend? Date of last attendance?
*
Your answer
Parent's Electronic Signature:
*
Your answer
Today's Date:
*
MM
/
DD
/
YYYY
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