MSD Lawrence Last Chance Enrollment Form

Open Enrollment Closes on August 31, 2023 at 11:59 PM EST

Parent/Guardian Name *

First

Last

Parent/Guardian Email *

Confirm Email

How many students/devices are you registering? *

Student Name *

First

Last

Student Grade *

Student School Building *

Student #2 Name *

First

Last

Student Grade #2 *

Student School Building #2 *

Student #3 Name *

First

Last

Student Grade #3 *

Student School Building #3 *

Student Name #4 *

First

Last

Student Grade #4 *

Student School Building #4 *

Student Name #5 *

First

Last

Student Grade #5 *

Student School Building #5 *

Student Name #6 *

First

Last

Student Grade #6 *

Student School Building #6 *

Acknowledgement of Coverage *

I acknowledge that my device is covered from the time ADP is purchased until July 31, 2024. If my device is damaged before ADP is purchased, this coverage does not apply.

Payment

Total

$ 0.00

Authorize.Net *

Card Number

Expiration

Security Code

Open Enrollment Closes on August 31, 2023 at 11:59 PM EST

Hours

Minutes