More Information - Charleston - Learn4Life-Charleston

Student Information

Student Name*

First Name Middle Name Last Name

Student's Date of Birth*

Gender (Circle One)

Current Grade Level

Please identify your ethnicity (Choose one of the options below)

Please identify your race (Choose the race you most closely identify with)

Parent Guardian Name

First Name Last Name

Address of Primary Residence

Street Address of Student's Primary Residence City State ZIP Code

Contact Phone Number*

Email Address*

Phone

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