Centurion Military Institute
A College Preparatory, Career & Technical Public Charter School
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Parent Interest Form

Please complete the following form to indicate your interest in enrolling your student(s) at Centurion Military Institute Charter School.

Fields marked with an asterisk ( * ) are required.   A Phone Number in one of the three Fields marked with double asterisks ( ** ) is required

Title:
  * First Name:
  M.I.:
  * Last Name:
  Suffix:
* Address Line 1:

Address Line 2:

* City:
  * State:
  * ZIP Code:
** Home Phone:
** Work Phone:
** Cell Phone:
* Email Address:

I am interested in enrolling the following student(s):

    Student Name   Curent Grade   Boy/Girl
 1       
 2       
 3       

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