Miguel Virtual Academy

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Student Registration

Student Information

Legal First Name*

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Legal Middle Name

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Legal Last Name*

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Preferred Name

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Grade Entering*

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Date of Birth*

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First language spoken by student*

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Languages spoken at home*

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Address

Street Address*

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City*

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Zip/Postal*

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Home Phone*

Number Required

Parent 1 Information

First Name*

Answer Required

Middle Name

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Last Name*

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Email*

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Mobile Phone*

Number Required

Work Phone

Number Required

Parent 2 Information

First Name*

Answer Required

Middle Name

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Last Name*

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Email*

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Mobile Phone*

Number Required

Work Phone

Number Required

Emergency Contact Information

First Name*

Answer Required

Middle Name

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Last Name*

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Relationship to Student*

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Email*

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Phone*

Number Required

Family Doctor Information

Name

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Phone

Number Required