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Student Enrollment Form 2020-2021

STUDENT ENROLLMENT FORM

Please complete the form below. Required fields marked with an asterisk *

A. STUDENT INFORMATION (Family Member Information)

Student Last Name, First Name, Middle*

Answer Required

ADDRESS

Street Address*

Answer Required

City*

Answer Required

State*

Answer Required

Zip/Postal*

Answer Required

Home Phone*

Number Required

Gender*

Answer Required

Male

Female

Date of Birth*

mm/dd/yyyy

Answer Required

Place of Birth: City | State/Province*

Answer Required

B. PARENT/LEGAL GUARDIAN:

WITH WHOM THE STUDENT LIVES (Caretaker Information)

Parent Last Name, First Name*

Answer Required

Home Telephone Number*

Number Required

Cell Phone Number*

Number Required

Work Telephone Number*

Number Required

Email Address*

Answer Required

Highest Level of Education Completed*

Answer Required

Does the student live with this parent/legal guardian?*

Answer Required

Yes

Relationship to Student:*

Answer Required

C. HOME LANGUAGE AND ETHNICITY INFORMATION

Home Language of the Student

Which language did this student learn when he/she first began to talk?*

Answer Required

Which language does this student most frequently use at home?*

Answer Required

Which language do you use most frequently to speak to this student?*

Answer Required

Which language is most often used by the adults at home?*

Answer Required

Has this student received any formal English language instruction (listening, speaking, reading, or writing)?

Answer Required

Yes

Is the student's ethnicity Hispanic/Latino?*

Answer Required

Yes

Student Primary Race *

(Mark one choice)

Answer Required

Student's Additional Race (Optional)

Answer Required

D. STUDENT EDUCATIONAL INFORMATION

Special Services

If you have any questions regarding this section, please refer to the brochure entitle " Are you Puzzled by Your Child's Special Needs?"

Was this student receiving special education services at his/her previous school?*

Answer Required

Yes

Did this student have a current Individualized Education Program (IEP) at the previous school?*

Answer Required

Yes

If Yes, do you have a copy of the student's IEP with you?*

Answer Required

Yes

N/A

Did this student have a Section 504 Plan at his/her previous school?

Answer Required

Yes

If Yes, do you have a copy of the student's Section 504 Plan with you?*

Answer Required

Yes

N/A

Does the student have difficulties that interfere with his/her ability to go to school or to learn?*

Answer Required

Yes

Has this student been identified for gifted and talented educational services (GATE)?*

Answer Required

Yes

Previous School Information

Has this student previously attended this school?*

Answer Required

Yes

If Yes, when? or type N/A if not applicable*

Answer Required

Has this student previously attended any other school or center in California (e.g., early education center, state preschool, SRLDP, Head Start, or other preschool)*

Answer Required

Yes

If Yes, list most recent school/center attended? or type N/A if not applicable*

Answer Required

Name of the School*

Answer Required

City

Answer Required

State

Answer Required

Dates Attended*

mm/dd/yyyy

Answer Required

Grade Level(s)*

Answer Required

Did you attempt to enroll the child in a different school in San Bernardino District for the current or preceding year? If No, skip to E*

Answer Required

Yes

If Yes, what was the outcome? *

Answer Required

If Other please provide information, type N/A if not applicable*

Answer Required

Please provide name of school:*

Answer Required

E. Is student currently under an expulsion order?

Answer Required

Yes

If Yes, please list the name of the school district: type N/A if not applicable*

Answer Required

Date of first California school enrollment excluding preschool *

(mm/dd/yyy)

Answer Required

E. ADDITIONAL HOUSEHOLD INFORMATION

Court Orders

Are there any court orders you wish to notify the school about regarding legal custody, physical custody or restricted contact with the school or child?

If yes, a copy of the court order must be provdided to the school.

Answer Required

Yes

Student Lives with a Foster Family

Answer Required

Yes

If Yes, is it a

Answer Required

Relative Caretaker

Non-relative Caretaker

Does the student have any relatives who are all or part American Indian or Alaska Native?

Answer Required

Yes

Has the student's parent or legal guardian worked in one or more of the following industries in the last three years (agriculture, dairy, fishery, food processing/packing, or livestock)?

If your respond Yes, you will be contacted at home regarding the Migrant Education Program and whether your child may qualify for its free academic assitance and health benefits.

Answer Required

Yes

F. Additional Family Information

Parent/Legal Guardian/Caregiver

Parent Last Name

Answer Required

Parent First Name

Answer Required

Parent Middle Name

Answer Required

Other Names Used

Answer Required

Address

Street Address

Answer Required

City

Answer Required

State

Answer Required

Zip/Postal

Answer Required

Home Telephone Number

Answer Required

Cell Phone Number

Answer Required

Work Telephone Number

Answer Required

Email Address

Answer Required

Highest Level of Education Completed

Answer Required

Not a High School Graduate

High School Graduate

Some College (includes AA Degree)

College Graduate

Graduate School/Post Graduate Training

Decline to State or Unknown

Does the student live with this individual?

Answer Required

Yes

Relationship to Student

Answer Required

ADDITIONAL SCHOOL AGE CHILDREN LIVING IN THE HOUSEHOLD WITH THE SAME PARENT(S)/LEGAL GUARDIAN(S) (include brothers, sisters, and cousins)

Child # 1 - Last Name, First Name, Middle Name and current school

Answer Required

Child # 2 - Last Name, First Name, Middle Name and current school

Answer Required

Child # 3 - Last Name, First Name, Middle Name and current school

Answer Required

Child # 4 - Last Name, First Name, Middle Name and current school

Answer Required

Child # 5 - Last Name, First Name, Middle Name and current school

Answer Required

G. Emergency Contact Information

Contact #1 - Last Name, First Name and relationship to student*

Answer Required

Contact # 1 - Phone Number*

Answer Required

Contact #2 - Last Name, First Name and relationship to student*

Answer Required

Contact # 2 - Phone Number*

Answer Required

Contact #3 - Last Name, First Name and relationship to student

Answer Required

Contact # 3 - Phone Number

Answer Required

Please list any food allergies or medical conditions your child may have:

Does your child have any food allergies?*

Answer Required

Yes

If you answer yes, please list what type of food allergies:

Answer Required

Does your child have any medical conditions?*

Answer Required

Yes

If you answer yes, please list what type of medical condition:

Answer Required

Please complete an allergy form and/or medication at school form. (Forms are available on our website)

Affirmation

We are very excited that you have chosen ASA Charter School for your student's education. We believe that family involvement is crucial to each student's success. ASA Charter School is your partner in the success of your student. We believe that academics are only one portion of your student's education and seek to empower students to become critical thinkers, effective communicators and life-long learners. It is our goal that our students will be responsible, productive citizens who demonstrate personal responsibility and are involved in their community. Therefore, in all aspects of our instruction we emphasize C.L.A.S.S.

Character: Doing what is right

Leadership: Being a positive example for others, influencing others in a positive way

Attitude: Everything you do is shaped by your attitude, Good Attitude = Good Results

Scholarship: Being a student, preparing for the future after high school

Service: Giving back to others, demostrating gratitude

ASA Charter School is a school of CHOICE. When you sign this agreement you are affirming the fact that you choose this school over all others that you are entitled to attend or have your child attend. In addition, your student can be referred back to their district home school for violations of the enrollment contract. For further details, rules and regulations of ASA Charter School, please refer to your Student Handbook.

ASA Charter School is a public charter school authorized under the provisions of California Education Code section 47600 et seq. In accordance with the provisions of Education code section 47605 (d) (1) its programs are non-sectarians. Furthermore, the school program shall be open to any eligible resident of California. No tuition will be charged to any pupil. No student may enroll in the school that is enrolled in any other school, except under the provisions of a currently completed co-enrollment agreement being in effect between both schools.

By your signatures hereto, you acknowledge the above limitations, and do hereby agree that the student shall not be enrolled in any school that charges tuition of any sort while enrolled in ASA Charter School.

Signature

I verify that the information contained in this document is true and correct to the best of my knowledge. I understand that this is an application to enroll in ASA Charter School and that the student is not enrolled until all information has been verified, all enrollment forms have been filled out, signed and dated and I have been notified that my student has been accepted for enrollment.

Signature of Legal Parent/Guardian:*

(Please type full name here)

Answer Required

Date*

Answer Required

Relationship to Student:

Answer Required

Parent

Legal Guardian

Other:

If Other, please specify

Answer Required

Thank you for taking the time to fill out this form. We look forward to working with you to help your child be successful in school!

Confirmation Email

Confirmation Email *

Email Required

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