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Application for Enrollment
Atkinson Academy Charter School K-12
ENROLLMENT FORM
I. STUDENT INFORMATION:
1.
Last Name
(LEGAL NAME ONLY):
First Name
Middle Name
Suffix (Jr, II, III)
2.
Gender:
M
F
3.
Other name(s) used previously (AKA):
4.
Birth Date:
5.
Ethnicity and Race (please respond to both 5a and 5b):
5a.
Are you Hispanic or Latino?
Y
N
5b.
Are you Hispanic or Latino?
American Indian/Alaskan Native
Asian/Chinese
Asian/Japanese
Asian/Korean
Asian/Vietnamese
Asian/Asian Indian
Asian/Laotian
Asian/Cambodian
Asian/Other Asian
Pacific Islander/Hawaiian
Pacific Islander/Guamanian
White
Pacific Islander/Samoan
Pacific Islander/Tahitian
Pacific Islander/Other
Filipino
Black/African American
Hmong
6.
Home phone:
7.
Household Address:
City, State:
ZIP Code:
8.
Mailing Address
(if different than household address):
City, State:
ZIP Code:
9.
City & State of Birth:
10.
Country of Birth:
11.
Student's residential status (check one):
Parent/legal Guardian
Foreign Exchange Student
Foster Family Home (FFH)
State Hospital
Licensed Children's Institution (LCI)
Developmental Center
Hospital (not state hospital)
Incarcerated Institution
Residential Facility
Other
12.
Has your child ever received Special Education services?
Yes
No
IF YES:
RSP
SDC
SPT
504
Date of last IEP (if known):
SELPA:
13.
Has your child ever been expelled from, currently expelled from or has a pending expulsion from any school district?
Yes
No
If so, which district/school
II. SIBLING INFORMATION:
14.
Complete this section only if applicable.
Include only siblings who are currently in Grades P-12 —use reverse side of form (Block 18), if needed.
Sibling 1 (full name):
Grade:
School:
Sibling 2 (full name):
Grade:
School:
Sibling 3 (full name):
Grade:
School:
III. CONTACT INFORMATION:
Please complete this entire section. You must provide information for
three contacts.
For additional contacts, use Block 18 on the reverse side of form.
15.
FIRST PARENT/GUARDIAN
16.
FIRST PARENT/GUARDIAN
17.
FIRST PARENT/GUARDIAN
Contact—full name
Relationship to student
Lives with student? (circle one)
Yes
No
If no, provide address here.
Yes
No
If no, provide address here.
N/A
Cell phone
Work phone
Home phone
Email address
N/A
Employer
N/A
Contact primary language
Receive Mail?
Yes
No
Yes
No
N/A
Parent Portal Access?
Yes
No
Yes
No
N/A
Education level (see below)
NHS
HS
SC
C
G
DEC
NHS
HS
SC
C
G
DEC
N/A
Education levels:
NHS=Not a high school grad HS=High school grad SC=Some college/AA degree C=College grad G=Graduate/Post grad DEC=Decline to state
ADDITIONAL INFORMATION AN D SIGNATURE REQUIRED ON REVERSE
IV. ADDITIONAL INFORMATION
(MUST BE COMPLETED FULLY)
18.
(Additional Information from Blocks 14 - 17)
19.
Are you now engaged in migrant work, or have you been engaged in migrant work (moved and worked seasonally in agricultural, lumber or fishery related jobs) in the last three years?
Yes
No
20.
Has your child ever played interscholastic athletics?
(For high school students only)
Yes
No
21.
Is it okay to release your child's information to military recruiters?
(For high school students only)
Yes
No
22.
Family Educational Rights and Privacy Act (20 USC §1232g; 34 CFR Part 99) Acknowledgement:
I am the parent or legal guardian of the student stated above and understand my right to request to review, receive a copy (at a reasonable fee), and/or challenge the records contained in my child's cumulative file.
23.
Anti-Discrimination Policy:
Atkinson Academy Charter School does not discriminate based on age, sex, race, color, religion, national origin, ethnic group, marital or parental status, physical or mental disability, medical condition, or any other unlawful consideration.
24.
Authorization to Request Student Records:
I am the parent/guardian of the student listed above, and I authorize student information to be requested so that I may enroll my child in the Atkinson Academy Charter School.
I understand the information contained in Sections I-IV. I affirm that the information provided in Sections I-IV is true to the best of my knowledge.
Please Print Name
Parent Signature (required)
Date
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