Power Center Academy Student Application 2008

Transcription

1 Power Center Academy Student Application 2008 Please print all information requested and send completed application to Power Center Academy, 6120 Winchester Road, Memphis, TN or fax to (901) Student General Information Grade Student is Entering Last Name First Name Middle Social Security Number Date of Birth Place of Birth Race Gender Home Address City State Zip Home Phone What is your primary language? Is English primary language spoken by student? Yes No Is English language limited? Yes No Parent/Guardian Information Mother Name Employer Work Phone Cell Phone Address Father Name Employer Work Phone Cell Phone Address Guardian Name (if other than parent) Employer Work Phone Cell Phone Address 1

2 Current School Information Current School Name Address City State & Zip Is the student currently enrolled in a Special Education or Resource Program? Yes No Does the student have any diagnosed disabilities? Yes No Does the student have any known health problems or illnesses? Yes No If yes, please list. Does the student take any medication? Yes No If yes, please list. Note: It is the responsibility of the parent/guardian to provide the school with specific emergency procedures. Does the student have a current Individualized Educational Program (IEP)? Yes No Has the student repeated a grade? Yes No 2

3 Has the student ever had any disciplinary difficulties in school? Yes No List the number of times the student has served in the following disciplinary programs: In School Suspension (ISS) Out of School Suspension School Detention Expulsion Does the student participate in any gifted or optional programs? Yes No 1. Emergency Contact Relation to Student Home Phone Cell Phone 2. Emergency Contact Relation to Student Home Phone Cell Phone Student Survey (Please have your child complete this portion of the survey) Check the areas that apply to you. I use computers at home. I use the Internet at home. I play computer games at home. I use the computer to complete my homework. Yes No This does not apply to me. 3

4 For Parent: Please give a brief essay as to why you want your child to attend Power Center Academy. Please indicate whether or not you will be able to volunteer at the school at least 3 hours a week. Yes No * We here at PCA believe it is imperative that the Parents be involved in their child s educational experience For Student: Please give a brief essay why you would like to attend Power Center Academy. 4

5 For Student: By signing this application, I am indicating that I understand that I must read and sign a Contract of Commitment before I enroll in Power Center Academy. I agree to adhere to all rules and regulations at Power Center Academy. I understand that I will not use any form of drug substance, tobacco, or partake of any alcoholic beverage while on campus or away from campus. Participating in such will be cause for immediate dismissal from Power Center Academy as outlined in the Student handbook. I do understand that if I decide that I do not want to adhere to the rules and regulations of PCA I will inform my teacher/principal so that I can voluntarily withdraw from PCA. I also realize that after I am accepted I will have to sign an agreement that I understand and accept the rules and regulations outlined in the Student Handbook. Student Signature Date For Parent or Guardian: By signing this application, I have read and understood the request for admission and the information requested. I have discussed with my child his/her decision to attend Power Center Academy. I hold true that all the information provided is accurate to my knowledge. I also understand that my child s teacher has full discretion to give my child detention if my child violates classroom disciplinary policies. I also understand that the school reserves the right to dismiss my child if he/she does not adhere to the rules and regulations outlined in the student handbook or if I as a parent am not willing to support the agreement outlined in the Contract of Commitment agreement. I understand that I will receive a parent handbook by mail and will adhere to the handbook once my student has been accepted. Parent/Guardian Signature Date For Office Use Only: Date application was received 5