Pinnacle | Enrollment Form

Pinnacle School Enrollment Form

Information entered on this and the following forms are *ENCRYPTED for privacy!

New student | Re-enrollment | Additional Student

Student's First Name: , Last Name: , Middle Initial:

Address: , Country: ,City:

State: , Zip:

Email: (*required)

Date of Birth: , ,

Student S.S.#: *

Student's Driver License #: *

Sex: Male | Female

Home Phone #: ()--, Work Phone #: ()--

Fax #: ()--

Grade: , Years Home Schooling:

Student Graduating in June this Year? Yes | No

Father's Name: ,Occupation:

Mother's Name: ,Occupation:

Father's Driver License #: *

Mother's Driver License #: *

A. Has student ever been suspended from any school within the last 2 years?

No | Yes, Approx. Date: , ,

B. Has student ever been arrested within the last 2 years?

No | Yes, Approx Date: , ,

How did you hear about Pinnacle School?

Select Curriculum Provider: (*required )

Check (*required )I have read the Compulsory Attendance Statute(s) and law(s) regarding homeschooling in/for my State and I am in agreement with both Pinnacle's
Statement of Purpose and beliefs and my *State's law(s), furthermore, I agree to abide by the statute(s)/law(s).

My signature grants Pinnacle School, and its staff permission to verify the data presented
in this form and to monitor compliance with Pinnacle School's rules and policies.

Typing your name(s) will constitute a valid signature.
Name of Parent(s) authorized to enroll this student and to obtain official Pinnacle school documents and/or correspondence.

Parent's Signature: , Date: , , (*required )

Parent's Signature: , Date: , ,

Note: False information submitted will result in immediate nullification of this enrollment!

*Some States may not recognize our distance learning program. Check before enrolling.