Enrollment — Coopers Academy

Cooper’s Learning Academy Enrollment Form

Thank you for your interest in Cooper’s Learning Academy! Please complete the form below to begin the enrollment process.

Student Full Name

Preferred Name/Nickname

Date of Birth

Age

Grade Level

Parent/Guardian Full Name

Email Address

Phone Number

Home Address

Current or Previous School

Academic Strengths
Areas Needing Support
Learning Differences or Special Accommodations

Select Program(s)

Full-Time Microschool

Part-Time Learning Support

Virtual Learning

One-on-One Tutoring

Preferred Start Date

Emergency Contact Name

Emergency Contact Phone

Allergies or Medical Conditions

Anything else you'd like us to know?

I certify that the information provided is accurate.