Scholar’s name:          Birth date:  //

Home address:         Race:   Select African American American Indian Asian Caucasian Hispanic

City:       Zip code:  

Scholar’s current school:  

Select term for admittance consideration: If later than fall of 2011 please use our preregistration enrollment option:   Select Spring of 2010 Fall of 2010 Spring 2011 Fall of 2011

Grade level for admittance term:   Select 8th 9th 10th 11th 12th |

Have you ever been expelled from another school?    Select Yes No

If yes, which one?  

Has applicant ever skipped a grade?    Select Yes No

Has applicant ever repeated a grade?    Select Yes No

Applying parent/Legal guardian name:  

Home# ()  Cell# ()

Valid e-mail address:  

If Applicable:
Spouse/Legal guardian name:  

Valid e-mail address:  

By submitting this application, I affirm to the best of my knowledge all information contained herein is complete and accurate.  I fully understand any false information, omissions or misrepresentations of facts may result in rejection of this application and/or future dismissal of the applicant.

Nota Bene:  All scholars must provide hard copies of their immunization records, social security card, birth certificate and academic transcripts to Haas Hall Academy before they will be allowed to attend classes.

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