KOOTENAI BRIDGE ACADEMY

Student Name: *


Date: *


Date of Birth: *


Age: *


Grade: *


Gender: *


Home Phone: *


Cell Phone: *


Who's phone numbers are these? *


Student Address: *


Parent/Guardian Name(s): *


Parent/Guardian Address: *


Whom do you live with? *


Parent/Guardian Email: *


Student Email: *


Are you attending school now? *


If you have dropped out, when did you? (month/year)


What high school did/are you attending? *


Approximate number of high school credits earned? You must be a Junior or Senior 16-20yrs of age to start @ KBA. *


Are you currently on an IEP, (Individual Educational Plan) 504, or do you receive special services? If so, which? *


Which shift are you interested in? 8-11am, 11-2pm, 2-5pm or 5-7:30pm (The 8-11am shift is currently full!) *


Relative or Friend to notify in case we can't reach your Parent/Guardian. Include Name, Phone Number & Relationship *