Please fill up the form ONLY IF YOU ARE SURE you want to enroll in our homeschool program.

Your Name:
Mother & Father's Professions:

Father's First Name:
Father's Last Name:
Father's Middle Initial:

Mother's First Name:
Mother's Last Name:
Mother's Middle Initial:

Parents living status:

Address: *

City: *
Zip:
Home Phone: *
Work Phone:
Cell Phone:
Email Address1:
Email Address2:

Student's First Name:
Student's Last Name:
Student's Middle Name:
Student's Gender: Male Femaie
Student's Birthday:*
Grade Level to Enroll:

Has this child been diagnosed as learning disabled in any way?*
 Yes No

If "Yes", please explain :

Last School's Name: *
School's Address:
School's City
School's Zip
School's Phone:
School's Fax:

Mode of Payment

Terms of Payment:

Do you want to order the textbooks? Additional Fees Apply
 Yes, I will order from HAP  No, I will get my own

Shipping Address If Textbooks Are Ordered