Student's Full Name: *

Student's Gender:
Boy Girl

Are you interested in seeing The Lippman School for more than one student?
Yes No

Student's Date of Birth: (MM/DD/YYYY)

Current Grade:
Select... Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade

Desired Grade of Entry:
Select... Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade

Desired Entry Year:
Select... 2013 2014 2015

Current School:

Please list all special interests, hobbies or favorite subjects for the student:

Would you prefer we call or email you to set up an appointment?
Call Email

Parent/Guardian 1

Title:
Select... Mr. Mrs.

Suffix

First Name: *

Last Name: *

Address:

City:

State:

Zip Code:

E-Mail Address: *

Phone: *

Relationship to student:
Select... Parent Guardian

Does the student live with you?:
Yes No

Parent/Guardian 2

Title:
Select... Mr. Mrs.

Suffix

First Name:

Last Name:

Address:

City:

State:

Zip Code:

E-Mail Address:

Phone:

Relationship to student:
Select... Parent Guardian

Does the student live with you?:
Yes No

Additional Information

How did you hear about The Lippman School?
Current Lippman School family
Lippman School alumni
Lippman School employee
Family or employee at your current school
Internet search
A Lippman School mailing
Print advertisement
Radio spot
Friend/Family
Tutor/Educational Consultant
Realtor
Relocation Service
Other

If a relative or close friend of yours has attended The Lippman School or had children who have attended or are currently attending, please let us know his/her/their name(s).

In your efforts to learn about The Lippman School, which of the following have you done so far?
Looked at the School's website
Attended an Open House or Drop-In Day
Spoken with current or past Lippman School families
Looked at the School's Facebook page

Help us prevent automated form submissions by identifying the
image below from the following list. *
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