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Cumberland Academy Enrollment Form

Parent/Guardian Information

Please fill out the form below to enter your students in the upcoming lottery

Parent First Name:	*
Parent Last Name:	*
Spouse (if applicable):
Street Address:	*
City:	*
State:	*
Zip Code:	*
Home Phone:	*	(###-###-####)
Other Phone:		(###-###-####)
Username:	*
Email Address:	*
Re-enter Email Address:
Accept Terms & Conditions:	*	(A check mark indicates agreement)

#	First Name*	Last Name*	Gender*	Birth Date*	School year*	Grade*
1			-- Select -- Female Male		-- Select -- 2010-2011	-- Select -- Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade
+ Add a Student

Please only complete this form if you are enrolling a New Student.