Student Application - Access Charter School

Student Information

First Name

Middle Name

Last Name

Home Address

Address Line 1

Address Line 2

City

Zip Code

Student History

Birth Date

Birth Place

Sex

Male Female

Race

Parent/Guardian Home Language

Student Native Language

State of Residence

Please answer the following questions

Is a language other than english used at home?

Yes No

If yes, what language?

Did the student have a first language other than English?

Yes No

If yes, what language?

Does the student most frequenly speak a language other than English?

Yes No

If yes, what language?

Has the student been identified as exceptional education?

Yes No

Student Medical Information

Physician's Name

Phone

Describe Heath Problems or Allergies

Medications

Contact Information

You need at least one contact marked as primary!

Last School Attended Information

School Name

School Type

Public Home Private

Address Line 1

Address Line 2

City

Zip Code

Has your child been staffed into an Exceptional Education Program through the school district?

Yes No

Name of the ESE Program(s)

What is your child's primary diagnosis?

Does your child have an IEP?

Signature

I give permission for the staff at Access Charter School to seek medical attention in case of an accident or injury or illness Yes No

I give permission for my child to be photographed while at school for the purpose of:

Instruction Yes No

Observation Yes No

Information/Advertisement Yes No

I give permission for my child to take field trips with Access Charter School including class walks Yes No

I agree to volunteer 15 hours to Access Charter School during the school year Yes No

I agree to attend the monthly parent meetings throughout the school year Yes No

I understand that my child's classroom may be under video surveillance throughout the day Yes No

Parent/Legal Guardian

Date

Access Charter School, Inc. does not disctriminate in admissions or access to, or treatment or employment in its programs and activities on the basis of race, age, sex, national origin, martial status, handicap or any other reason prohibited by law.

Please review your application, there are some fields that require your attention.