Risen Star Academy New Student
Membership Application 
Please fill out this page for EACH STUDENT you are registering with RSA.


This form must be re-submitted each year.

Please read the following statement and sign at the end of this Form.

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Email *
Registering for: *
Student's name, FIRST NAME
 (one student per form)
 *
Student's LAST NAME *
Student's gender *
Student's ethnicity/race *
Grade for upcoming year

**Reminder Grades K & 7 require updated immunization form DH680 IF we do not already have an exemption Form DH681 on file
 *
Student's Home Address (street address) *
Student's Home Address (City, State & Zip) *
Student's Date of Birth *
MM
/
DD
/
YYYY
Previous School Name *
Parent / Guardian Information:
Name (please list both parents)
 *
Parent / Guardian Contact phone number *
Fees may be paid online or mailed, per website. *
Late Fee *
REPORT ATTENDANCE HERE 
 *
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