sais id #: enrollment 2014-‐2015 academic year

WESTERN SCHOOL OF SCIENCE AND TECHNOLOGY: A Challenge Foundation Academy
(623) 933-­‐ 3773
SAIS ID #:
ENROLLMENT 2014-­‐2015 ACADEMIC YEAR
STUDENT INFORMATION
LAST NAME
FIRST NAME
ETHNICITY: (Mark ONLY ONE)
Hispanic/Latino
RACE: (Mark ONE or MORE of the following)
American Indian/Alaska Native
Black or African American
NOT Hispanic/Latino
Asian
STUDENT DATE OF BIRTH (MM/DD/YYYY)
/
MIDDLE INITIAL
Hawaiian/Other Pacific Islander
White
BIRTH CITY
AGE:
GRADE LEVEL APPLYING FOR
STUDENT LIVES WITH:
BOTH PARENTS
GENDER: M | F
BIRTH STATE
MOTHER ONLY
OTHER
FATHER ONLY
BIRTH COUNTRY
/
PREVIOUS SCHOOL INFORMATION
NAME OF SCHOOL LAST ATTENDED
PREVIOUS SCHOOL INFORMATION (City, State, Zip if known)
WITHDRAWAL DATE (MM/DD/YYYY)
/
/
PARENT/LEGAL GUARDIAN INFORMATION
PRIMARY CONTACT NAME (Last, First)
OK to Pick-­‐up
SECONDARY CONTACT NAME (Last, First)
Legal Custody
Lives With
OK to Pick-­‐up
Receives Mail
HOME ADDRESS
Legal Custody
Lives With
Receives Mail HOME ADDRESS
CITY
STATE
ZIP CODE
CITY
MAILING ADDRESS (If Different From Above)
CITY
ZIP CODE
STATE
ZIP CODE
MAILING ADDRESS (If Different From Above)
STATE
HOME PHONE [__] Check if Primary
(
)
CELL PHONE [__] Check if Primary
(
)
EMAIL ADDRESS
STATE
ZIP CODE
CITY
WORK PHONE [__] Check if Primary
(
)
RELATIONSHIP TO STUDENT
HOME PHONE [__] Check if Primary
(
)
CELL PHONE [__] Check if Primary
(
)
EMAIL ADDRESS
WORK PHONE [__] Check if Primary
(
)
RELATIONSHIP TO STUDENT
PERSONS OTHER THAN PARENT WHO CAN ASSUME TEMPORARY RESPONSIBILITY IN CASE OF EMERGENCY
EMERGENCY CONTACT 1 NAME (Last, First) *AUTHORIZED TO PICK UP STUDENT*
EMERGENCY CONTACT 2 NAME (Last, First) *AUTHORIZED TO PICK UP STUDENT*
HOME PHONE
(
)
CELL PHONE
(
)
HOME PHONE
(
)
CELL PHONE
(
)
WORK PHONE
(
)
RELATIONSHIP TO STUDENT
STUDENT BACKGROUND
WORK PHONE
(
)
RELATIONSHIP TO STUDENT
HOME LANGUAGE SURVEY
If parents are separated/divorced, who has legal custody? ______________________ 1. What is the primary language used in the home REGARDLESS of the language
Does the non-­‐custodial parent have restricted visitation rights? ___Yes ___No
(If "yes" a copy of the legal paperwork must be provided)
spoken by the student?
Does your child currently receive Special Services?
2. What is the language the student first acquired?
Special Education/IEP
504
___Yes ___No
ELL or LEP
Has your child ever been expelled from another school?
___Yes ___No
3. What language is most often spoken by the student?
Is your child currently under a long-­‐term suspension? ___Yes ___No
Admission to Western School of Science and Technology: A Challenge Foundation Academy is open to any resident of the State of Arizona. Western: CFA will not charge students tuition and will not discriminate against any student on the basis of ethnicity, national origin, citizenship, religion, gender, or disability.
Completion of this form does not guarantee admission to Western School of Science and Technology: CFA. Priority is given to returning students and their siblings. The remaining seats will be awarded to new applicants in a public lottery on May 1, 2014. Remaining applicants will be placed on a waiting list in the order they are drawn in the lottery. Applications received after May 1, 2014 will be added to the end of the waiting list on a first come, first serve basis.
TO THE BEST OF MY KNOWLEDGE THE INFORMATION I HAVE PROVIDED ON THIS FORM IS ACCURATE AND TRUE (FALSIFICAITON OF INFORMATION IS A CLASS 6 FELONY §ARS 13-­‐2407).
X
SIGNATURE OF PARENT/GUARDIAN
DATE
WESTERN SCHOOL OF SCIENCE AND TECHNOLOGY: A Challenge Foundation Academy
(623) 933-­‐ 3773
SAIS ID #:
ENROLLMENT 2014-­‐2015 ACADEMIC YEAR
INFORMACION DEL ESTUDIANTE
APELLIDO
NOMBRE
EDNICIDAD: (Marque uno)
Hispanic/Latino
RAZA: (Marque uno o mas de los siguientes)
NO Hispanic/Latino
Indio Americano/Nativo de Alaska
Asiatico
FECHA DE NA CIMIENTO (MM/DD/YYYY)
/
INICIAL
EDAD:
ESTUDIANTE VIVE CON:
DOS PADRES
Negro o Africano Americano
Hawaiano/Otro Isleno Pacifico
Blanco
CIUDAD DE NACIMIENTO
GRADO ESCOLAR
GENERO: M | F
MADRE
OTRO
PADRE
ESTADO DE NACIMIENTO PAIS DE NACIMIENTO
/
INFORMACION DE LA ESCUELA PREVIA
NOMBRE DE LA ESCUELA PREVIA
DIRECCION DE PREVIAESCUELA (Ciudad, Estado, Codigo Postal) ULTIMO DIA DE BAJA (MM/DD/YYYY)
/
/
INFORMACION DEL PADRE/GUARDA LEGAL
NOMBRE DE CONTACTO PRIMARIO (Apellido, Nombre)
Bien recoger
Custodia Legal
NOMBER CE CONTACTO SECUNDARIO (Apellido, Nombre)
Vive con
Recive Correo
DIRECCION
Bien recoger
Custodia Legal
Vive con
Recive Correo DIRECCION
CIUDAD
ESTADO CODIGO POSTAL
DIRECCION DE CASA (Si es diferente)
ESTADO CODIGO POSTAL
DIRECCION DE CASA (Si es diferente)
CUIDAD
ESTADO CODIGO POSTAL
TELEFONO DE CASA [__] Primero de Llamar
(
)
CELULAR [__] Primero de Llamar
(
)
CORREO ELECTRONICO
CIUDAD
NUMERO DE TRABAJO [__] Primero de Llamar
(
)
RELACION CON ESTUDIANTE
CUIDAD
ESTADO CODIGO POSTAL
TELEFONO DE CASA [__] Primero de Llamar
(
)
CELULAR [__] Primero de Llamar
(
)
CORREO ELECTRONICO
NUMERO DE TRABAJO [__] Primero de Llamar
(
)
RELACION CON ESTUDIANTE
PERSONAS ADEMAS DEL PADRE QUE PUEDE ASUMIR RESPONSABILIDAD TEMPORAL EN CASO DE EMERGENCIA
1. CONTACTO DE EMERGENCIA (Apellido, Nombre) *Autorizado para leventar estudiante*
2. CONTACTO DE EMERGENCIA (Apellido, Nombre) *Autorizado para leventar estudiante*
TELEFONO DE CASA
(
)
NUMERO DE CELULAR
(
)
TELEFONO DE CASA
(
)
NUMERO DE CELULAR
(
)
NUMERO DE TRABAJO
(
)
RELACION CON ESTUDIANTE
ANTECEDENTES DEL ESTUDIANTE
NUMERO DE TRABAJO
(
)
RELACION CON ESTUDIANTE
CUESTIONARIO DE LENGUA DE CASA
1. What is the primary language used in the home REGARDLESS of the language
Si padres estan separados/divorciados, quien tiene custodia legal? ______________________
___Si
El padre sin custodia tiene derechos de visitacion restringidos?
___No
spoken by the student?
(Si es "si" se requiere una copia del papel legal)
Actualmente su hijo(a) recive educacion especial?
Educacion Especial/IEP
504
___Si
___No
2. What is the language the student first acquired?
ELL o LEP
Su hijo(a) ha sido expulsado de otra escuela?
Su hijo(a) esta bajo un termino largo de suspencion?
___Si
___Si
___No
3. What language is most often spoken by the student?
___No
Admisió a la escuela Western School of Science and Technology: A Challenge Foundation Academy está abierta a cada residente del estago de Arizona. Western: CFA no cobre para la ensenñanza y no discrimina en contra de ningún estudiante por su origen étnico, nacionalidad, ciudadaniía, religion, sexo o incapacidad.
Llenar este formulario no garantiza la admision a Western School of Science and Technology: A Challenge Foundation Academy. Se da prioridad a los estudiantes actuals que regresan a Western: CFA y sus hermanos. Los puestos que quedan se regalarán a los aplicantes nuevos en una lotería pública en el 1 de mayo de 2014. Aplicaciones que quedan serán colocadas en una lista de espera en el orden en que se escogen por la lotería. Aplicaciones recibidas después del 1 de mayo 2014 se añadirán al final de la lista de espera por orden de que fueron recibidas.
TO THE BEST OF MY KNOWLEDGE THE INFORMATION I HAVE PROVIDED ON THIS FORM IS ACCURATE AND TRUE (FALSIFICAITON OF INFORMATION IS A CLASS 6 FELONY §ARS 13-­‐2407).
X
FIRMA DEL PADRE/GUARDA LEGAL
FECHA