NEW Student Enrollment
Account Request
This form is the first step to enrolling your new student online. Complete it to request an account that you will use to log in to a secure system.
Complete required fields to request an account to enroll your student(s).
Enter the name of the legal parent/guardian of the student you want to enroll
Guardian Legal First Name:
Guardian Legal Last Name:
Guardian Legal Middle Name:
Guardian Legal Name Prefix:
AUDIOLOGIST
DOCTOR
Medical Doctor
P.A.C.
Guardian Legal Name Suffix:
APNP
CCC
DDS
DR
DRSC
II
III
JR
MD
OD
PA-C
PAC
RN
SR
Guardian contact information
Guardian Email Address
:
Re-type Email Address
:
Guardian Primary Phone Number:
Complete the security dialog
Asterisk (*) denotes a required field
Click here to submit Account Request