Application to Family Membership Family Membership Questionnaire Application to Family Membership Applicant's Legal Name Birth Date Phone Email Mailing Address How did you hear about us? (Whom may we thank?) Are your children enrolled in Academy Northwest? Yes No College Degree? Yes No If you have a Teaching Certificate, please provide Certificate # State of Issue Expiration Date Graduation Major Minor Other Endorsements Degree(s) Earned (check all that apply) Masters Bachelors Associates Name(s) of institutions from which degree(s) earned ASCI # Household Members - Please list all children who will be under your supervision. Child's Name: Birthdate Sex M F Grade Level KindergartenFirstSecondThirdFourthFifthSixthSeventhEighthNinthTenthEleventhTwelfth Additional Child - Name: Birthdate Sex M F Grade Level KindergartenFirstSecondThirdFourthFifthSixthSeventhEighthNinthTenthEleventhTwelfth Additional Child - Name Birthdate Sex M F Grade Level KindergartenFirstSecondThirdFourthFifthSixthSeventhEighthNinthTenthEleventhTwelfth Additional Child - Name Birthdate Sex M F Grade Level KindergartenFirstSecondThirdFourthFifthSixthSeventhEighthNinthTenthEleventhTwelfth Additional Child - Name Birthdate Sex M F Grade Level KindergartenFirstSecondThirdFourthFifthSixthSeventhEighthNinthTenthEleventhTwelfth reCAPTCHA Submit Δ
