Kaplan College Preparatory

Affiliate Student Form

Homebound Coordinator:	*
Homebound Coordinator Email:	*
School Name:	*
Student Name:	*
Administrative/Medical:

Grade:	*
Date of Birth:	*
Length of Enrollment (in months or weeks):
Estimated Start Date:
Home Phone:	*
Cell Phone:
Email Address:	*
Address:	*
Address 2:
City:	*
State:	*
Zip Code:	*

	Parent/Guardian 1	Parent/Guardian 2
Name:
Home Phone:
Work Phone:
Cell Phone:
Address (if different from student):
City:
State:
Zip Code:

Course Requested:	Start Week:	End Week:








Student Special Needs:

Student Academic Needs:

(*) Indicates Required Field