Student Name: We look forward to a wonderful school year and can t wait for you to join us! Thank you!

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1 Welcome to Belmont Charter High School! We re so excited that you will be joining us for the school year. This packet contains all of the necessary forms, documents and information we need for official student enrollment. Once we receive all of your paperwork, we will send you a confirmation to the listed on your child s application. We will also use this address to send school updates and information throughout the summer. In August, we will mail home a packet with a few additional forms needed to start the school year. The packet will include a student profile, emergency contact sheet and health forms along with a request for updated physical and dental assessments. We look forward to a wonderful school year and can t wait for you to join us! Thank you! Student Name: Required Documentation: Complete Enrollment Packet Proof of Residency (Any 2 of the following are acceptable: deed, lease, mortgage agreement, notarized Residency Agreement, current utility bill, current credit card bill, property tax bill, vehicle registration, driver s license, and DOT identification card) Proof of Age (Any of the following are acceptable: birth certificate, baptismal certificate, passport, notarized statement indicating date of birth, prior school records showing date of birth) Student Immunization Records Recommended Documentation: In order to ensure proper placement and best meet the needs of every student, we ask that you provide any of the following documentation that you have available. Please note that these documents are not required, but are very helpful to us as we work through the enrollment process. Student Physical Assessment Records Student Dental Examination Records Copy of Student Health Insurance Card Final 7 th Grade, & 8 th grade 1 st Quarter School Records (Academic, Attendance, IEP, Disciplinary, etc.) *A release form is included for us to obtain your final 8 th grade records. School Contact Information Building Address: 1301 Belmont Avenue, 3 rd Floor Philadelphia, PA Phone Number: Address: (Please include student name in the subject line.)

2 Belmont Charter High School Student Enrollment Notification Form School Year School Name: Belmont Charter High School Building Address: 1301 Belmont Avenue, 3 rd Floor Philadelphia, PA School Contact: Main Office Phone Number: Address: (Please include student name in the subject line.) Student Information: Last Name: First Name: MI: Home Address: City: State: Zip Code: County: Mailing Address (if different from home address): City: State: Zip Code: Primary Phone Number: Secondary Phone Number: Date of Birth: Age: School District of Residence and Former School Information: School District of Residence: Former School Information: Public School Charter School Home School Non-Public School Student was not enrolled in school preceding enrollment at Belmont Charter High School because: Not of School Age Re-Enrolling Dropout Other: Previous Grade: Withdrawal Date From Former School: *Is your child receiving special education services based on an IEP? YES NO *If YES, do you have a copy of your child s special education records (IEP)? YES NO *Has your child ever received behavior support services (1-on-1 support (TSS), in-school counseling, etc.)? YES NO

3 Parent/Guardian Information: Child lives with: Both Parents Both Parents Alternately Mother Only Father Only Legal Guardian Foster Parents Other Adult (Please Specify): Special Custodial Court Instructions (If yes, please provide a copy of the court order): YES NO Complete Parent/Guardian Name and Address Information (*Please complete all applicable sections) Father s Name: City: State: Zip Code: Primary Phone Number: Secondary Phone Number: Address: Mother s Name: City: State: Zip Code: Primary Phone Number: Secondary Phone Number: Address: If this student is not living with their parent(s), please complete this section: Guardian s Name or Foster Parent s Name or Other Adult Name Name: City: State: Zip Code: Primary Phone Number: Address: My signature on this form indicates my decision to have my child attend Belmont Charter High School and signifies my request that appropriate school records be forwarded from the School District to the Charter School. Signature of Parent/Guardian: Date:

4 Home Language Survey (PA Requirement) The office of Civil Rights (OCR) requires that school districts/charter schools/full fall day AVTS identify limited English proficient (LEP) students in order to provide appropriate language instructional programs for them. Pennsylvania has selected the Home Language Survey as the method for identification. School District: Philadelphia School: Belmont Charter High School Date: Grade: 1. What is/was the student s first language? 2. Does the student speak a language(s) other than English? (Do not include languages learned at school) YES NO If YES, specify the language(s): 3. What languages is/are spoken in your home? 4. Would you like school documents sent home in another language? If yes, please specify: YES NO 5. Has the student attended any United States school in any 3 years during his/her lifetime? YES NO If YES, complete the following: Name of School State Dates Attended Person completing this form (if other than parent/guardian): Parent/Guardian Signature: Date: * The school district/charter school full day AVTS has the responsibility under the federal law to serve the students who are limited proficient and need English instructional services. Given this responsibility, the school district/ charter school/full day AVTS has the right to ask for the information it needs to identify English Language Learners (ELLs). As part of the responsibility to locate and identify ELLs, the school district/charter school/ Full day AVTS may conduct screenings or ask for related information about students who are already enrolled in the school as well as from students who enroll in the school district/ charter school/ full day AVTS in the future.

5 Belmont Charter High School Registration Statement Student Name: Date of Birth: Grade Level: 9 10 Parent/Guardian Name: Home Phone: Cell Phone: According to the School Code of Pennsylvania, which governs and operates all public schools in the state, section A states in part that Prior to admission to any school entity, the parent, guardian or other person having control or charge of a student shall, upon registration provide a sworn statement or affirmation stating whether the pupil was previously or is presently suspended or expelled from any public or private school of this Commonwealth or any other state for an action of offense involving a weapon, alcohol or drugs, or for the willful infliction of injury to another person or for any act of violence omitted on school property. I hereby swear or affirm that my child (Please circle): WAS WAS NOT previously suspended or expelled and/or IS IS NOT presently suspended or expelled from any public or private school for an act or offense involving weapons, alcohol or drugs, or for the willful infliction of injury to another person or for any act of violence committed on school property. I make this statement subject to the penalties of 24 P.S A (b) and 18 Pa. C.S.A. 4904, relating to unsworn falsification to authorities. If convicted under these sections, I will be sentenced to pay a fine. Understanding the consequences of providing false information, I state the facts contained herein are true and correct to the best of my knowledge, information and belief. If this student has been or is presently suspended or expelled from another school, please complete: Name of the school district from which the student was suspended or expelled: Dates of suspension and/or expulsion: Reason for suspension and/or expulsion: Signature of Parent/Guardian: Date:

6 Belmont Charter High School Consent for Release of School Records To Whom It May Concern: I hereby authorize the release of all school records, including but not limited to past report cards, Individualized Education Plans, attendance records, interim reports, and behavior documentation reports from: School: Address: City: State: Zip Code: Telephone: Fax: And to communicate as needed with the school leadership and/or teachers of the following student: Student: Date of Birth: Address: City: State: Zip Code: Name of Parent/Guardian: Please or mail any requested information to: School Registrar: School: Mailing Address: Main Office Belmont Charter High School 1301 Belmont Avenue, 3 rd Floor Philadelphia, PA Phone Number: Address: I understand that the information provided will be used to assist in the placement and educational services of my child. I understand that this authorization will remain in effect from the date hereof to the end of the current school year unless sooner revoked by me in writing at any time. Signature of Parent/Guardian: Date:

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