Augsburg Fairview Academy Application for 2012-13

If you wish to apply to the Academy for next year, please provide as much information as possible. Thank you.

*NAME:  First, Last

*Last Name

*Grade you will be in NEXT year:

9 10 11 12

*Date of Birth:

Student Contact Information

*Address Line 1:

Address Line 2:

Apt. or Suite No.

*City:

*State:

*Zip Code:

*Phone where student can be reached:

Alternate Phone:

Cell Phone:

Student E-mail:

Family Contact Information

Contact Information for Legally Reponsible Adult

*Relationship:

*First Name:

*Last Name:

*Address Line 1:

Address Line 2:

Apt. or Suite No.

*City:

*State:

*Zip Code:

*Day Phone:

Night Phone:

E-Mail:

Contact Information for Second Person

Relationship:

First Name:

Last Name:

Address Line 1:

Address Line 2:

Apt. or Suite No.

City:

State:

Zip Code:

Day Phone:

Night Phone:

E-Mail:

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