There was an error trying to submit your form. Please try again. Beyond the Bell Academy Student Enrollment Form Parent/Guardian Information Parent/Guardian Full Name * This field is required. Relationship to Student * This field is required. Parent/Guardian Email * This field is required. Primary Phone Number * This field is required. Secondary Phone Number This field is required. Home Address Address Line 1 * This field is required. Address Line 2 This field is required. City * This field is required. State * This field is required. Postal Code * This field is required. Country * Select an option Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia, Plurinational State of Bosnia and Herzegovina Botswana Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, The Democratic Republic of the Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran, Islamic Republic of Persian Gulf Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic of Korea Korea, Republic of South Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory, Occupied Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Reunion Saint Barthelemy Saint Helena, Ascension and Tristan Da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Sudan South Georgia and the South Sandwich Islands Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan Tanzania, United Republic of Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Venezuela, Bolivarian Republic of Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Yemen Zambia Zimbabwe This field is required. Preferred Contact Method * Phone Call Email Text Message This field is required. Student Information Student's Full Name * This field is required. Student Preferred Name/Nickname This field is required. Student Gender * Male Female Prefer not to say Prefer to self-describe This field is required. If you selected "Prefer to self-describe", please specify Student Birthdate * This field is required. School Name * This field is required. Grade Level * This field is required. Emergency Contacts Emergency Contact #1 Full Name * This field is required. Relationship to Student * This field is required. Phone Number * This field is required. Emergency Contact #2 Full Name * This field is required. Relationship to Student * This field is required. Phone Number * This field is required. Authorized Individuals for Pick-Up Authorized Individual #1 Full Name * This field is required. Relationship to Student * This field is required. Phone Number * This field is required. Authorized Individual #2 Full Name This field is required. Relationship to Student This field is required. Phone Number This field is required. Authorized Individual #3 Full Name This field is required. Relationship to Student This field is required. Phone Number This field is required. My child has permission to sign themselves out Medical Information Does your child have any allergies? If so, please list them Does your child have any medical conditions we should know about? Does your child require any special accommodations? If so, please list them Additional Student InformationThis section is optional, but it will help us personalize your child’s experience Please list some of your child's interests and/or hobbies Does your child need assistance with any subjects in school? If so, please list them Is there anything about your child's learning style or behavior that would help our mentors support them? Is there anything else you would like us to know about your child? Permissions I would like to be notified about future programs and events from Beyond the Bell Academy I give permission for Beyond the Bell Academy to use photographs and/or videos of my child on the organizations’s website, social media, printed materials, and promotional content. I give permission for my child to participate in Beyond the Bell Academy activities * This field is required. I understand that it is my responsibility to notify Beyond the Bell Academy of any changes to my child’s emergency contacts, medical information, and/or authorized pick-up individuals * This field is required. Parent/Guardian Electronic Signature * This field is required. Today's Date * This field is required. Submit There was an error trying to submit your form. Please try again.
