Radiant STEM Academy -

The following fields in red are required:

Parent/Guardian Information

Father's First Name

First name is required.

Father's Middle Name

Father's Last Name

Last name is required.

Mother's First Name

First name is required.

Mother's Middle Name

Mother's Last Name

Last name is required.

Street Address

Street address is required.

City

City is required.

State

State is required.

Zip Code

Zip code is required.

Primary Phone #

Primary phone # is required.

Mother's Cell Phone

Father's Cell Phone

Additional Phone #

Mother's email address

Enter a valid email.

Father's email address

Enter a valid email.

Child {{$index + 1}} Information

First Name

First name is required.

Middle Name

Last Name

Last name is required.

Date of Birth

Date of birth is required.

Gender

Male Female

Gender is required.

Grade Applying For

Grade applying for is required.

Ethnicity

Hispanic or Latino Not Hispanic or Latino

Ethnicity is required.

Race (select all that apply)

American Indian/Alaska Native Asian Black Native Hawaiian/Other Pacific Islander White

Previous School Attended

Previous Grade

Street Address

City

State

Zip Code

Phone #

Email address

Enter a valid email.

I verify that I provided the information accurately.

Signature:

Electronic signature is required.

Date:

Date is required.

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