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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 for "Student Last Name, First Name, Middle"

ADDRESS

Street Address*

Answer required for "Street Address"

City*

Answer required for "City"

State*

Answer required for "State"

Zip/Postal*

Answer required for "Zip/Postal"

Home Phone*

Number Required

Gender*

Answer required for "Gender"

Male

Female

Date of Birth*

mm/dd/yyyy

Answer required for "Date of Birth"

Place of Birth: City | State/Province*

Answer required for "Place of Birth: City | State/Province"

B. PARENT/LEGAL GUARDIAN:

WITH WHOM THE STUDENT LIVES (Caretaker Information)

Parent Last Name, First Name*

Answer required for "Parent Last Name, First Name"

Home Telephone Number*

Number Required

Cell Phone Number*

Number Required

Work Telephone Number*

Number Required

Email Address*

Answer required for "Email Address"

Highest Level of Education Completed*

Answer required for "Highest Level of Education Completed"

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

Answer required for "Does the student live with this parent/legal guardian?"

Yes

Relationship to Student:*

Answer required for "Relationship to Student:"

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

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

Answer required for "Which language does this student most frequently use at home?"

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

Answer required for "Which language do you use most frequently to speak to this student?"

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

Answer required for "Which language is most often used by the adults at home?"

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

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

Yes

Is the student's ethnicity Hispanic/Latino?*

Answer required for "Is the student's ethnicity Hispanic/Latino?"

Yes

Student Primary Race *

(Mark one choice)

Answer required for "Student Primary Race "

Student's Additional Race (Optional)

Answer required for "Student's Additional Race (Optional)"

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

Yes

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

Answer required for "Did this student have a current Individualized Education Program (IEP) at the previous school?"

Yes

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

Answer required for "If Yes, do you have a copy of the student's IEP with you?"

Yes

N/A

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

Answer required for "Did this student have a Section 504 Plan at his/her previous school?"

Yes

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

Answer required for "If Yes, do you have a copy of the student's Section 504 Plan with you?"

Yes

N/A

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

Answer required for "Does the student have difficulties that interfere with his/her ability to go to school or to learn?"

Yes

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

Answer required for "Has this student been identified for gifted and talented educational services (GATE)?"

Yes

Previous School Information

Has this student previously attended this school?*

Answer required for "Has this student previously attended this school?"

Yes

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

Answer required for "If Yes, when? or type N/A if not applicable"

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 for "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)"

Yes

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

Answer required for "If Yes, list most recent school/center attended? or type N/A if not applicable"

Name of the School*

Answer required for "Name of the School"

City

Answer required for "City"

State

Answer required for "State"

Dates Attended*

mm/dd/yyyy

Answer required for "Dates Attended"

Grade Level(s)*

Answer required for "Grade Level(s)"

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 for "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"

Yes

If Yes, what was the outcome? *

Answer required for "If Yes, what was the outcome? "

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

Answer required for "If Other please provide information, type N/A if not applicable"

Please provide name of school:*

Answer required for "Please provide name of school:"

E. Is student currently under an expulsion order?

Answer required for "E. Is student currently under an expulsion order?"

Yes

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

Answer required for "If Yes, please list the name of the school district: type N/A if not applicable"

Date of first California school enrollment excluding preschool *

(mm/dd/yyy)

Answer required for "Date of first California school enrollment excluding preschool "

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 for "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? "

Yes

Student Lives with a Foster Family

Answer required for "Student Lives with a Foster Family"

Yes

If Yes, is it a

Answer required for "If Yes, is it a"

Relative Caretaker

Non-relative Caretaker

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

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

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 for "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)? "

Yes

F. Additional Family Information

Parent/Legal Guardian/Caregiver

Parent Last Name

Answer required for "Parent Last Name"

Parent First Name

Answer required for "Parent First Name"

Parent Middle Name

Answer required for "Parent Middle Name"

Other Names Used

Answer required for "Other Names Used"

Address

Street Address

Answer required for "Street Address"

City

Answer required for "City"

State

Answer required for "State"

Zip/Postal

Answer required for "Zip/Postal"

Home Telephone Number

Answer required for "Home Telephone Number"

Cell Phone Number

Answer required for "Cell Phone Number"

Work Telephone Number

Answer required for "Work Telephone Number"

Email Address

Answer required for "Email Address"

Highest Level of Education Completed

Answer required for "Highest Level of Education Completed"

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 for "Does the student live with this individual?"

Yes

Relationship to Student

Answer required for "Relationship to Student"

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

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

Answer required for "Child # 2 - Last Name, First Name, Middle Name and current school"

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

Answer required for "Child # 3 - Last Name, First Name, Middle Name and current school"

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

Answer required for "Child # 4 - Last Name, First Name, Middle Name and current school"

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

Answer required for "Child # 5 - Last Name, First Name, Middle Name and current school"

G. Emergency Contact Information

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

Answer required for "Contact #1 - Last Name, First Name and relationship to student"

Contact # 1 - Phone Number*

Answer required for "Contact # 1 - Phone Number"

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

Answer required for "Contact #2 - Last Name, First Name and relationship to student"

Contact # 2 - Phone Number*

Answer required for "Contact # 2 - Phone Number"

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

Answer required for "Contact #3 - Last Name, First Name and relationship to student"

Contact # 3 - Phone Number

Answer required for "Contact # 3 - Phone Number"

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

Does your child have any food allergies?*

Answer required for "Does your child have any food allergies?"

Yes

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

Answer required for "If you answer yes, please list what type of food allergies:"

Does your child have any medical conditions?*

Answer required for "Does your child have any medical conditions?"

Yes

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

Answer required for "If you answer yes, please list what type of medical condition:"

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 for "Signature of Legal Parent/Guardian:"

Date*

Answer required for "Date"

Relationship to Student:

Answer required for "Relationship to Student:"

Parent

Legal Guardian

Other:

If Other, please specify

Answer required for "If Other, please specify"

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 *

Answer required for "Confirmation Email"

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