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 for "Student Last Name:"

Student First Name:*

Answer required for "Student First Name:"

Birthdate:*

Answer required for "Birthdate:"

Grade:*

Answer required for "Grade:"

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

Answer required for "2. Has your child ever been retained (held back)?"

Yes

If yes, what grade?

Answer required for "If yes, what grade?"

3. Has your child ever been expelled?*

Answer required for "3. Has your child ever been expelled?"

Yes

If yes, for what reason?

Answer required for "If yes, for what reason?"

What district?

Answer required for "What district?"

Is the expulsion cleared?

Answer required for "Is the expulsion cleared?"

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

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

Yes

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

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

Signature of Parent/Legal Guardian:*

(Please type full name here)

Answer required for "Signature of Parent/Legal Guardian:"

Date:*

Answer required for "Date:"

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.