Student Enrollment Form

Instructions: Fill out the following information completely and sign and date the last page.
Notify us immediately if any of your information changes

W526 Division Street, Stephenson, MI 49887 | Phone: (313) 335-3218 | www.uplift-mi.org

Student Information

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1 Step 1
Are you an eligible student who is 18 or older or an emancipated minor enrolling yourself?(if no, fill out parent/guardian information)
Parent/Guardian Information
Type of Phone
Preferred Method of Contact:
Best time of day to contact you?
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Enroll Today

NEED HELP WITH ENROLLMENT? CALL 313-335-3218 
We look forward to hearing from you.