Please Select the School you are interested in: *

SHELIA Y. OLIVER ACADEMY

CICELY L. TYSON ELEMENTARY

WHITNEY HOUSTON ACADEMY

WAHLSTROM ACADEMY (Program Begins 11/6/2023)

J. GARFIELD JACKSON ACADEMY (currently not accepting applications)

JOHNNIE COCHRAN ACADEMY (currently not accepting applications)

START DATE *

MM

DD

YYYY

Child's Name *

First Name

Last Name

Child's Date of Birth *

MM

DD

YYYY

Child's Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mother's Name

First Name

Last Name

Mother Employers Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mother Cell Phone Number

(###)

###

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Father's Name

First Name

Last Name

Father Employers Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Father Cell Phone Number

(###)

###

####

E1 Name *

First Name

Last Name

E1 Phone *

(###)

###

####

E2 Name

First Name

Last Name

E2 Phone

(###)

###

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Name *

First Name

Last Name

Method of Payment *

Confirmed Program for Parents

Pending Program for Parents

Out-Of-Pocket $80/per week

Other

*

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