ACE/YouthWorks Charter High Schools

ACE/YouthWorks Charter High Schools
Student Data Collection Form
ACE/YouthWorks Charter High Schools are a public High School that students can receive a Diploma
from.
Date: ________________________
Name: _______________________________ Age. ___________ DOB: __________________________
(Please Circle)
Gender: Male / Female
Ethnicity: Hispanic / Latino (Hispanic/Latino not a race, please make race selection)
Race: White / African-American / American Indian / Asian / Native Hawaiian or Pacific Islander
Address: __________________________________________________Zip________________________
Home Phone: _____________________________Message Phone: _______________________________
Name of Parents Employment: ________________________Work Phone #________________________
Have you previously attended ACE Charter High School? Yes__________
Prior Special Education Placement: Yes____ No____
No_________
Current IEP: Yes_____ No_______
Last School Attended: _________________________________________________________________
Other high schools attended: _____________________________________________________________
Participation in a program for the Gifted: Yes_______ No________
Why did you leave? ____________________________________________________________________
Grade completed: ________________
Number of Credits at this Time: ___________________
Have you ever been suspended? Yes_____ No_____
Are you presently involved in any juvenile court adjudication or are on probation? Yes___ No___
If yes, what is your Probation Officer’s Name? ______________________ Phone# _________________
Are you or your family receiving any kind of welfare assistance?
Are you: Single Parent _______
Yes______ No_____
Foster Child _______ Youth On Their Own_______
Are you currently employed? Yes ______
No ______
Where? _________________________________________
Preferred Schedule hours: ________ 8:20am – 12:42pm
Hours: __________________________
________ 10:59am – 3:25pm
OFFICIAL USE ONLY:
SAIS ID: ________________
Initial: __________
Entered in
SchoolMaster on: __________
Entry
Date/Code: ___________
School Official Signature: _______________________________________
ACE/YouthWorks Charter High School
Forma de Datos del Estudiante
ACE/YouthWorks Charter High School es un instituto publico que pueden recibir un diploma de la
escuela.
Fecha: ________________________
Nombre: ______________________________ Edad:_____ Fecha de Nacimiento:_______________
(Escoja Una)
Sexo: Masculino / Femenino
Raza:
Blanco-Europeo
Origen Etnico: Hispano / Latino
(Seleccionar su raza)
Negro-Africano Americano
Indigena-Nativo Americano
Asiatico-Oriental
Nativo Hawaiano
Domicilio:__________________________________________Codigo Postal:_____________________
Teléfono residencial:____________________________ teléfono de mensaje:______________________
Nombre de Empleo de Padres:__________________________ Teléfono de Trabajo:________________
Asistió anteriormente a ACE Charter High School?
Previa Educación Especial: No _____
Participación en programa para talento:
Si ______
Si _____
Si _____
No ______
Actual IEP:
Si ____ No ____
No ______
Todas escuelas preparatorias que asistió: _________________________________________________
Porqué dejo la escuela(s)? ______________________________________________________________
El grado que completó: ________
Ha estado suspendido?
Número de créditos que ha completado:___________________
Si _____
No ______
Actualmente está implicado en cualquier sentencia tribual de menores o en libertad condicional?
Si______
No ________
Si es, qué es el nombre del Oficial? ____________________________
Usted o su familia recibe cualquier clase de ayuda de bienestar?
Usted es: Padre/Madre Soltera(o) ____
Esta trabajando?
Si_____
Telefono#_______________
Si ____
hijo adoptivo _____
No____
joven independiente ______
No _____
Donde? ____________________________________________ Horas? __________________________
Horario preferido: ______ 8:20am – 12:42pm
_______ 10:59am – 3:25pm
PARA USO DE ADMINISTRACION SOLAMENTE:
SAIS ID: _________________
Inicial: ________________
Inscribir en
Schoolmaster: ___________
Fecha y Codío
de Registro: ____________
Firma de Administracion: _________________________________