SU'COY Community Learning Center.

Dated :

Participant :

Print :

Witness :

New Student Registration Form

Student Legal Name :

Student Preferred Name/Nikname :

Name Nikname

Gender :

Male Female

Date of Birth :

Enrolling Program :

Year Student entering program :

20 Does not apply

Name of Sibling(s) currently attending Su'Coy Community Learning Center.

Name of Sibling:

Date of Birth :

Previous Education Information

Name of Last School Attended :

Last School Attended Telephone :

School Type (Check all that apply) :

Public Private Home Education

City/State last School Attended :

Country of last School Attended :

USA Other:

Special Services Information / Education Plan (Please check all that apply) :

IEP ESL Title 504 EST Other:

Grade Level at last Attended School :

Last Date Attended School :

Does the student have a High School Diploma or GED ?

Yes No

Student Place of Birth (City, State, Country) :

Citizenship Status :

US Citizen Other

Country of Citizenship ( if not U.S. ) :

Student Home Telephone^* Unlisted:

Student Email :

^* Student Home telephone is the primaru number to be used by alert Now for regular notifications (School closings)

Physical Address of Student and Enrolling Parent/Guardian Street #

Mailing Address (if different from Physical) Street Street Name, Apt no, City, State, Zip

Ethnic Group and Race Categories. The Federal and State government requires that both these questions be answered and provides only the following categories for ethnic group and race. If questions I and 2 are not answered, school personnel are to make selection for both.

1. Is this student Hispanic or Latino? (choose only one)

Yes No

2. What is the student's race (check all that apply)

American Indian/Alaskan Native Asian Black or African American Native Hawaiian Pacific Islander White

Are there court orders of which the school should be aware? Yes No If yes, please provide documentation with this registration

Student ID :

Student is an Immigrant

Yes No (If Yes please fill out next boxes l-4)

Year First slarted school in Year entered country (United States) Immigrated From First date enrolled in US school

Migrant Status :

Yes No (In the last three ycars have you moved with family/guardian in search of temporary or seasonal work in agricultune or logging.)

Student is in state Care and Custody :

Yes No (I Yes. please fill continue to fill out the rest of this section.)

Caseworker Name :

Caseworker Phone Day Cell: Night Cell

Agency Name and Address (Street #, Street Name, Apt no, City, State, Zip) :

1. Parent/Guardian Information

Name :

Relationship :

Mother Father (Legal Guardian)

Lives with Student :

Full Time Part Time

Has custody of Student :

Yes No

Gets Mailing for Student :

Yes No

Education Completed | 12th grade (choose highest completed level) :

Some college 2 Year College Degree 4 Yrs College Grad School GED

Home Phone Unlisted :

Day or Cell Phone Unlisted :

Day or Cell Phone Phone Unlisted :

Email :

Address if not the same as student's physical (Street #, Street Name, Apt no, City, State, Zip) :

Employer :

2. Parent/Guardian Information

Name :

Relationship :

Mother Father (Legal Guardian)

Lives with Student :

Full Time Part Time

Has custody of Student :

Yes No

Gets Mailing for Student :

Yes No

Education 8th grade | 9th grade | 10th grade | 1 I th grade | 12th grade (choose highest completed level) :

Some college 2 Year College Degree 4 Yrs College

Requires a translator : Yes No

Correspondence Language :

Home Phone Unlisted :

Day or Cell Phone Unlisted :

Day or Cell Phone Phone Unlisted :

Email :

Address if not the same as student's physical (Street #, Street Name, Apt no, City, State, Zip) :

Employer :

Provide the name(s) of person(s), other than the parent, allowed to pick up student or to call in case of an emergency

Name (first, middle initial, last) :

Relationship to :

Telephone #

Home Application Form

Application Form

RELEASE AND WAIVER OF LIABILITY, AGREEMENT NOT TO SUE, AND INDEMNIFICATION AND HOLD HARMLESS AGREEMENT

New Student Registration Form

Previous Education Information

Are there court orders of which the school should be aware? Yes No If yes, please provide documentation with this registration

1. Parent/Guardian Information

2. Parent/Guardian Information

SU'COY Community Learning Center

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