Editing previous response:

Please fix the highlighted areas below before submitting.

Application to Enroll 2019-2020 School Year

Student's First Name*

Answer Required

Student's Middle Name

Answer Required

Student Last Name*

Answer Required

Student Date of Birth*

mm/dd/yyyy

Answer Required

Resident of LAUSD?*

Answer Required

Yes

If yes, what LAUSD school would your child attend?

Answer Required

Is there a sibling who is currently enrolled at Extera Public School?*

Answer Required

Yes

If yes, name of sibling

Answer Required

Parent First Name*

Answer Required

Parent Middle Name

Answer Required

Parent Last Name*

Answer Required

Street Address*

Answer Required

City*

Answer Required

State*

Answer Required

Zip Code*

Answer Required

Home Phone Number

(555) 555-5555

Answer Required

Cell Phone Number

(555) 555-5555

Answer Required

Email Address*

Answer Required

Signature*

Answer Required

By checking this box and typing my name, I certify that all information on this form is true and correct. I also agree that the checkbox and my name typed below are to be used as my electronic signature, and I am indicating that I am meaningfully interested in enrolling the above named child in Extera Public School for the 2019-2020 School Year. I understand that signing this form does not guarantee enrollment at Extera Public School. I further understand that this information will be disclosed to the Los Angeles Unified School District to support the Extera Public School request for facilities under Proposition 39, and that LAUSD may contact me directly to verify my response.

Enter your name below*

Answer Required

Confirmation Email

Enter your email address here if you'd like to receive a confirmation upon submitting the form.