Student Services Questionnaire 2021-2022

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

STUDENT SERVICES QUESTIONNAIRE 2021-2022

School: ASA CHARTER SCHOOL

Student Last Name:*

Answer Required

Student First Name:*

Answer Required

Birthdate:*

Answer Required

Grade:*

Answer Required

2. Has your child ever been retained (held back)?*

Answer Required

Yes

If yes, what grade?

Answer Required

3. Has your child ever been expelled?*

Answer Required

Yes

If yes, for what reason?

Answer Required

What district?

Answer Required

Is the expulsion cleared?

Answer Required

Yes

4. Where is your child/family currently living? (Check one box only.)

This information will be used to determine if your child qualifies for any additional assistance under the No Child Left Behind Act of 2001.

Answer Required

In a single family residence

With more than one family in a house or apartment due to economic hardship

In a motel, car or campsite

In a foster care placement

Other:

5. Are any of your child's parents/legal guardians on Active Military duty?*

Answer Required

Yes

If yes, (which parent(s)/guardian(s), branch and start/end dates, if known):

Answer Required

Signature of Parent/Legal Guardian:*

(Please type full name here)

Answer Required

Date:*

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!

Please fix the highlighted areas below before submitting.