Child's Name *

First Name

Last Name

Gender *

Male

Female

Date of Birth *

MM

DD

YYYY

Parent's Name *

First Name

Last Name

Parent's Cell *

(###)

###

####

Parent Name

First Name

Last Name

Parent's Cell

(###)

###

####

Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

School Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

School Phone

(###)

###

####

Has your child ever had any educational testing done? *

Yes

No

Date given:

MM

DD

YYYY

Application Fee *

A non-refundable $25 application fee is due with this form. After the submission of this form, payment must be sent as a check in the mail to: "283 Lafayette Street, Bridgeport, CT 06604 USA" or via paypal.com to: "contact@bridgeporthopeschool.org" (Your name and the reason for the payment must be put in the paypal comment box.) You may also come in to the school and pay via cash, check, or credit card. This application is not valid and will not be considered until payment is received.

Yes, I understand that this application will not be considered until the $25 non-refundable application fee is paid and I will pay via one of the methods mentioned above after the submission of this form.