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* Gender: |
Select Male or Female |
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Birth Date: |
Birth Date month is Required
Birth Date day of month is Required
Birth Date year is Required
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*Ethnicity: |
Select Ethnicity |
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* Address: |
Address is Required |
* Phone: |
A Phone Number is Required |
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Fax: |
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* City: |
City is required |
* Email: |
Email address needs to be in this format: name@company.suffix Example eschool@pisd.edu If you are pasting an address, remove any spaces and brackets <>.
Email Address is Required |
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* Confirm Email: |
Email address needs to match the one above.
Confirmation Email Address is Required |
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* State:
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Select a State
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or Province: |
Select a state or province
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* ZIP / Postal code: |
ZIP or postal code is required |
Country:
(If not U.S.) |
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* Graduation Date
(MM/YYYY): |
/
Select a graduation month
Select a graduation year |
* Current grade level: |
Select a grade level |
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Parent / Guardian's Information |
*
Parent / Guardian's name: |
Parent Name is Required |
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Address:
(if different from student's) |
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* Phone: |
Parent Phone is Required |
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Email: |
Email address needs to include an @ symbol and a period. Also remove any leading or trailing spaces.
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City: |
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or Province: |
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State: |
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Country: (if not U.S.) |
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ZIP / Postal code: |
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Parent 2 Name:
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Parent 2 Email:
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Email address needs to include an @ symbol and a period. Also remove any leading or trailing spaces.
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Parent 2 Phone:
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School Information |
(If you are home schooled, the following information
is not required.) |
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* School
School District Name:
* Other School Name: |
Select a School
Enter the other school name
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* School Counselor/Contact: |
School Counselor/Contact is Required |
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Address: |
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Contact Title: |
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* Contact Phone #: |
Contact Phone Number is Required |
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City: |
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Contact Email: |
Email address needs to include an @ symbol and a period. Also remove any leading or trailing spaces.
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State: |
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or Province: |
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ZIP / Postal Code: |
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Country: (if not U.S.) |
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* School Next Semester: |
Select a School or Other
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Payment Information |
* Payment Method: |
Select a Payment Method |
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Credit Card Processing |
* Card Type: |
Card type is required.
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Name On Card: |
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* First:
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First name is required.
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* Last: |
Last name is required.
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* ZIP Code: |
Billing ZIP code is required.
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* Card Number: |
Enter numbers only. Omit any "-". Make sure you have selected the correct card type. |
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* Expiration Date: |
Expiration month is required.
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Expiration year is required.
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