195 Commercial Drive, Suite 100 London, KY 40744

New Student Application
General Information

nullnullnull
First Name
Last Name
Middle Name
Home Phone
Cell Phone
Email
Campus
Street
City
State
Zip Code
Birth Date
Gender Male Female
Ethnicity
Teacher
Picture File
Program


Guardian Contact Information

Guardian Name
Relationship
Phone
Email
Street
City
Zip Code
State
Country


Permanent Contact Information

City
Street
State
Zip Code
Country
Phone


Emergency Contact Information

Lead Name
Relationship
Home Phone
Work Phone
Cell Phone


Disability Information

DisabilityYes NoNot Selected
Disability Description
Learning DifficultiesYes NoNot Selected
Learning Difficulties Description



Tuition & Fees Payment Information

Tuition Rate
Payment Method
Payment Plan Full Payment







All tuition and fees will be billed according to this payment plan.



Enter the above code
 Required