* Required Information

Student Information

*Legal name at time of enrollment:
	*First	Middle	*Last

*Date of Birth:

Month

select Jan Feb March April May June July Aug Sept Oct Nov Dec

Day

select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Year

select 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961

*Gender:

Male Female

*High School where student would have graduated:
*Expected Year of Graduation:
Student ID # (lunch number):

*Has student previously applied for a Waiver or Variance?

Yes No

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Primary Contact Information

*Name:
*Address Street 1:
Address Street 2:
*City:	*State:  select AA AE AK AL AP AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR OS PA PR RI SC SD TN TX UT VA VT WA WI WV WY  *Zip:
*Email Address:
*Phone Number:

*By clicking the "Agree" box, I verify the above information is complete and accurate. Agree