EXHIBIT
OPEN ENROLLMENT
ATTENDANCE APPLICATION
File this application at your current school office
Student's name _________________________________________________
Last First M.I.
Current grade _______________ Birth date __________________________
Parent/Guardian Information: Must be listed on Birth Certificate or Legal Custody Documentation
Student Lives with: ____ Both Parents ____ Mother Only ____ Father Only
____ Guardian ____ Foster ____ Other, please specify:________________
For joint Legal Decisiion-Making, please indentify Primary Parent/Guardian:
____ Mother ____ Father
Mother's name __________________________________________________
Last First M.I.
Home address __________________________________________________
Street City Zip
Home phone _____________ Message _____________ Cell _____________
E-mail address __________________________________________________
Father's name __________________________________________________
Last First M.I.
Home address __________________________________________________
Street City Zip
Home phone _____________ Message _____________ Cell _____________
E-mail address __________________________________________________
The above-named student: ◻ resides outside the School District; or
◻ resides within the School District
Present school of attendance:
School _________________________ City __________________________
Request assignment to ___________________________________________
Is the above-named student:
Participating in or will the student need participation in any special school programs? (Resource, learning disabled, gifted, et cetera) ◻ Yes ◻ No If yes, please complete the section titled "Special Programs."
Expelled or long-term suspended from any school or school district? ◻ Yes ◻ No
Out of school pending further disciplinary action such as expulsion or long-term suspension from any school or school district? ◻ Yes ◻ No
Is in compliance with conditions imposed by a juvenile court? ◻ Yes ◻ No ◻ N/A
Is in compliance with a condition of disciplinary action in any school or school district? ◻ Yes ◻ No ◻ N/A
Other siblings who attend or will be attending school:
Student's
name _________________________________________________________
Last First Current grade School
Student's
name _________________________________________________________
Last First Current grade School
Student's
name _________________________________________________________
Last First Current grade School
Special Programs
Please identify any special programs your child has participated in or special help received from previous school personnel and any anticipated special school programs or services.
◻ My child has participated in or it is anticipated will need to participate in the program(s) or receive the services listed below:
◻ Gifted/Talented
◻ Special Education/Exceptional Student Services
Please check all that apply:
◻ Adaptive Physical Education ◻ Occupational Therapy
◻ Speech/Language Therapy ◻ ESS/SPED (self-contained)
◻ Resource ◻ Vision
◻ Special Education Preschool ◻ Hearing
◻ Physical Therapy ◻ Assistive Technology
◻ Transportation as "related service"
◻ Section 504 (school will need current Accommodation Plan)
◻ English Learner Program (EL)
◻ Other (explain) ___________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
The signatory affirms that the student will abide by the rules, standards, attendance requirements, and policies of the school and District if enrolled.
Proof of Residence must be provided with application.
___________________________________ _________________________
Signature of Parent or Legal Guardian Date
Providing false information on this form may result in the application being denied or admission revoked.
FOR DISTRICT USE ONLY *** DO NOT WRITE BELOW THIS LINE
Student's full name _______________________________________________
Student number ______________________ Date stamp ________________
Filing Date
◻ Accepted
◻ Placed on waiting list
◻ Rejected - Reason for rejection ___________________________________
Principal _______________________________________ Date ___________