Editing previous response:

Please fix the highlighted areas below before submitting.

Application to Enroll 2019-2020 School Year

Student's First Name*

Student's Middle Name

Student Last Name*

Student Date of Birth*

mm/dd/yyyy

Resident of LAUSD?*

Yes

If yes, what LAUSD school would your child attend?

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

Yes

If yes, name of sibling

Parent First Name*

Parent Middle Name

Parent Last Name*

Street Address*

City*

State*

Zip Code*

Home Phone Number

(555) 555-5555

Cell Phone Number

(555) 555-5555

Email Address*

Signature*

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*

Confirmation Email

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