Inspire Learning Academy, Inc. Online Registration

Registration

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Welcome to ILA! Please complete the following registration form:

* denotes required fields

Referral Information

Referral Name

Family Information

Family Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Primary Phone*

Additional Info

Emergency Contact Info (Not Contact #1 or #2)*

Health Insurance Carrier*

Contact #1

Contact #1 First Name*

Last Name *

How Can We Contact You?

Home Phone

Work #

Cell # *

Receive Text Message Notifications. By opting in, you agree to receive SMS messages from Inspire Learning Academy, Inc.. Standard message and data rates apply. Reply STOP to opt out

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Contact #2

Contact #2 First Name

Last Name

How can we contact you?

Home Phone

Work #

Cell # * Receive Text Message Notifications. By opting in, you agree to receive SMS messages from Inspire Learning Academy, Inc.. Standard message and data rates apply. Reply STOP to opt out

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

Grade Level*

Special Needs

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

IEP

Med. Alert

Photo Release: Yes or No*

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

Grade Level*

Special Needs

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

IEP

Med. Alert

Photo Release: Yes or No*

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

Grade Level*

Special Needs

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

IEP

Med. Alert

Photo Release: Yes or No*

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

Grade Level*

Special Needs

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

IEP

Med. Alert

Photo Release: Yes or No*

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

Grade Level*

Special Needs

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

IEP

Med. Alert

Photo Release: Yes or No*

Add Another Student

Required Policies

(Show-Hide Details)

Questions or Concerns

Comments

Payment Information

Credit Card

Card Number *

Exp Month *

Exp Year *

Card Nickname

Name as it appears on card *

Address Line 1

Address Line 2

City

State

Zip*

Registration

Referral Information

Family Information

Where do you live?

Additional Info

Contact #1

How Can We Contact You?

Portal Access (your email is your login)

Contact #2

How can we contact you?

Student #1

Additional Info

Student #2 (Show-Hide Details)

Additional Info

Student #3 (Show-Hide Details)

Additional Info

Student #4 (Show-Hide Details)

Additional Info

Student #5 (Show-Hide Details)

Additional Info

Required Policies (Show-Hide Details)

I Agree to All of the Above

Questions or Concerns

Payment Information

Credit Card

Required Policies

(Show-Hide Details)