Enrollment Form

Student Information:

Last Name: _____________________ First Name: __________________ Middle: ________

Nickname: _____________________ SSN: ___________________________ Sex: M or F

Birth Date: ___________ Age as of September 1, 20XX: ______Birthplace: ______________

Ethnicity:(circle one) Native American Asian/Pacific Islander African American

Hispanic White

Home Address: ______________________________________________________________

City: _________________________________ State: ____ Zip: ________________________

Home Phone: __________________________ Email: _______________________________

Parent/Guardian Information

Full Name: _______________________ Relationship:_________ Home Phone:___________

Home Address: __________________________ Work Phone:_________________________

Work Place: ______________ Birthplace: ___________ Ethnicity: ___ Speaks English: Y / N

Full Name: _______________________ Relationship:_________ Home Phone:___________

Home Address: __________________________ Work Phone:_________________________

Work Place: ______________ Birthplace: ___________ Ethnicity: ___ Speaks English: Y / N

Full Name: _______________________ Relationship:_________ Home Phone:___________

Home Address: __________________________ Work Phone:_________________________

Work Place: ______________ Birthplace: ___________ Ethnicity: ___ Speaks English: Y / N

Emergency Phone Numbers (other than parents)

Name:____________________Phone:__________________Relation:___________________

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Special Pick-up Instructions:_________________________________________________

__________________________________________________________________________

New Student Information

Student Name: _______________________________________Grade________________

Previous School: __________________________________________________________

Address: ________________________________________________________________

Special Programs: _________________________________________________________

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Parent/Guardian: __________________________________________________________

Have you done migrant work, on a temporary or seasonal basis, in a job related to

agriculture, forestry or fishing? Circle: Yes or No

If yes, did your child/children travel with you when you went to work or looked for work? Circle: Yes or No

Students are at time involved in activities that are videotaped or photographed. Sometimes the videotape or photograph is used by the media or shown to parent organizations. I give XYZ charter school permission to videotape or photograph my child in classroom activities.

Circle: Yes or No

If I cannot be contacted in case of emergency, I hereby authorize the individuals listed on the XYZ Charter School emergency card to be notified at the school’s discretion. XYZ Charter is committed to being a DRUG-FREE, WEAPON-FREE, VIOLENCE-FREE school. I understand that my child will receive a XYZ Charter School student handbook explaining the code of student conduct and consequences to students who violate school policy. I understand that my child will be subject to school discipline and possibly to criminal prosecution if he/she is found to have violated XYZ Charter’s Code of Student Conduct, which prohibits the use of possession, sale or distribution of illicit drugs and alcohol, possession of weapons, and involvement in any violent act on school premises or at any school activity.

Failure to sign this form does not exempt your child from compliance with the laws, policies, rules, and regulations of the state and school. All the information we ask for is required to complete the student record. Please fill out accurately and sign.

Signature of Parent/Guardian: _________________________ Date: ____________________

Student Registration Date: __________ Time: _______ Date Entered XYZ: ______________

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