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Enroll at Heartland High School

Please complete the information below to start the application process. Once submitted, our staff will contact you.

For further assistance or questions, email info@heartlandhighschool.org

Student Information

First Name*

Last Name*

Date of Birth*

Month

Day

Year

Sex*

Grade*

Address*

City*

State*

Zip Code *

Cell Phone Number*

Email*

Last School Attended*

Does the student currently use substances or have a history of substance use? Please briefly explain. *

Parent/Guardian Information

First Name*

Last Name*

Relationship to Student*

Cell Phone*

Work Phone

Email*

Address (If Different From Student)

City

State

Zip Code

Parent/Guardian 2

First Name

Last Name

Relationship to Student

Cell Phone

Work Phone

Email

Address (If Different From Student)

City

State

Zip Code

How did you hear about Heartland?

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QUICK LINKS

(614) 947-1115

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