ENROLL

Enrollment Form

Vista Charter Middle School (LA) Enrollment Form

The questions that are marked by an asterisk (*) are mandatory

Grade Level *:

Student Information

Student's First Name and Last Name*:
Student's Middle Name (Initial):
Gender *:
Street Address *:
City *:
State *:
Zip/Postal:
Date of Birth *:

Family Information (Based on student's Birth certificate)

Father:

First Name and Last Name:
Primary Phone/Mobile Phone:

Mother

First Name and Last Name:
Primary Phone/Mobile Phone *:

Please complete this section based on who student lives with

Guardian 1

Stepfather:
First Name and Last Name:
Primary Phone/Mobile Phone:

Guardian 2

Guardian relationship:
First Name and Last Name:
Primary Phone/Mobile Phone:
Primary Residence *:

Court Orders

ARE THERE ANY COURT ORDERS RESTRICTING THE LEGAL RIGHTS OF EITHER PARENT?
IF YOU ANSWER IS "YES", YOU HAVE TO PROVIDE A COPY OF THE COURT ORDER TO THE SCHOOL OFICE:

Emergency Contact Information

Authorized person to care for/pick up the student if parent/care provider(s) cannot be reached.

In case the school is unable to reach the parent or guardian during any emergency, you authorized the school admits to contact to any of the following. Also you authorized to release your child to any of the following:

Emergency Contact 1

First Name *:
Last Name:
Relationship:
Primary Phone *:

Emergency Contact 2

First Name:
Last Name:
Relationship:
Primary/Mobile Phone:

Home Language Survery

What language did this student learn when first began to talk?:
What language does this student most frequently use at home?:
The language you use most frequently to speak to this student.:
Which language is most often used by adults at home?:
Please specify what is the other language.:
Has this student received any formal English language instruction (listening, speaking, reading, or writing)?:

Previous School Information

Date of first U.S. school enrollment:
Has student previously attended this school or any Vista Charter Public School?:
If yes, When? What Grade?:

Please list last two schools previously attended

School Name:
School Name:

Special Services

A- Did this student receive special education services at his/her previous school?:
B- Did this student have an Individualized Educational Program (IEP) at his/her previous school?:
C- Did this student have a Section 504 Plan at his/her previous school? :
D- Does this student have difficulties that interfere with his/her ability to go to school or learn? :
If the answer of any of the above question is YES, please provide a copy of related documents.

SIGNATURE

I verify that this information is true and correct
Please print your name as your signature here*:
Date:
Signature of:
Confirmation Email *: