Student Services Questionnaire 2025-2026

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

STUDENT SERVICES QUESTIONNAIRE 2025-2026

School: ASA CHARTER SCHOOL

Student Last Name:*

Answer required for "Student Last Name:"

Student First Name, Middle Name*

Answer required for "Student First Name, Middle 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

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):"

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 you repsonded YES, you will be contacted at home regarding the Migrant Education Program and whether your child may qualify for it's free academic assistance and/or 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?"

Yes

Are you interested in our After School Program?*

Answer required for "Are you interested in our After School Program?"

Yes

If Yes, how many students?

Answer required for "If Yes, how many students?"

Are you interested in our Early Start Program?*

Answer required for "Are you interested in our Early Start Program?"

Yes

If Yes, how many students?

Answer required for "If Yes, how many students?"

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.

Student Services Questionnaire 2025-2026