Enrollment Download Application Step 1 of 4 25% Student InformationStudent Name* First Middle Last Student Home Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Student Mailing Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code If different from home address.Date of Birth* Date Format: MM slash DD slash YYYY Age* School District of Residence and Former School InformationSchool District of Residence*Former School Information*Public SchoolCharter SchoolHome SchoolNon-Public SchoolStudent Not Enrolled in School Preceding Enrollment in Charter SchoolOther than Pre-School.ReasonEntering KindergartenRe-Enrolling DropoutName of Former School*Address of Former School* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Previous Grade*Withdrawal Date from Former School* Date Format: MM slash DD slash YYYY Was your child receiving Special Education Services based on an IEP?*YesNoDo you have the child's Special Education Records (IEP)?*YesNo Parent/Guardian InformationChild Lives With:*Both ParentsBoth Parents AlternatelyMother OnlyFather OnlyLegal GuardianFoster ParentsSpecial Custodial Instructions?*YesNoProvide a copy of court order.Complete Parent/Guardian Name and Address Information As ApplicableStudent Lives with Parent(s)*YesNoFather's Name First Last Father's Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Father's Home PhoneFather's Work PhoneMother's Name First Last Mother's Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Mother's Home PhoneMother's Work PhoneStudent Lives With:GuardianFoster ParentGuardian Name First Last Guardian Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Guardian Home PhoneGuardian Work Phone Sign and Complete My signature on this form indicates my decision to have my child attend the charter school named on page 1 of this form and signifies my request that appropriate school records be forwarded from the school district to the charter school. My signature also certifies that my child is not, and will not be, enrolled in another public school, a non-public school or a private school at the same time he or she is enrolled in this charter school.Signature of Parent/Guardian*Please type your full name.Date* Date Format: MM slash DD slash YYYY
