Required Documents Enrollment Form pages 1-7 Birth Certificate Immunizations Proof of Residency High School Only: unofficial transcript Enrollment Form 2016-2017 School Year **You must be the student s parent or legal guardian to fill out this enrollment form.** Students 18 years or older must fill out the enrollment for themselves. Student Enrollment Information Student s Legal Name (Last, First, Middle) Birth Date Sex Birth State (in US) or Country (outside US) What is the student s grade level for the current school year (7/1/2016 to 6/30/2017)? What is the student s race? (circle all that apply) Is the student Hispanic or Latino? Yes / No White Black/African American Asian American Indian or Alaska Native Native Hawaiian/Other Pacific Islander This student will be attending Sequoia Choice for: (check all that apply) Full time enrollment Part time enrollment/concurrently enrolled at another school Summer School enrollment ONLY Credit Recovery Special Program: Williamsburg Special Program: Early College Credit If you selected Summer School, Credit Recovery, or Part Time enrollment, which classes do you need to take with us? What is the best phone number to contact the student directly? Each student will be provided with a Google Student e-mail to be used for school purposes only, including homework and contacting advisors/teachers. Students in grades 7-12 will need to check their student e-mail daily. This account will be deleted upon withdrawal. Home Address City, State, ZIP Mailing Address (if different from above) City, State, ZIP Primary Contact Information PRIMARY Parent / Guardian (for students age 18 and above please use your own information and list relationship as SELF ) Last, First Relationship to student E-mail Primary Phone Number (circle one) Cell / Home / Work Alternative Phone Number (circle one) Cell / Home / Work Site Start Date : Other notes or requests: Please list an e-mail account that is checked frequently and at least one reliable phone number. The Primary Parent/Guardian will receive the student s start-up information and any school updates. For home-based students, this individual will be responsible for entering attendance and supervising the student s work/progress at home. 1
2 Additional Contact Information Additional Contact #1 Last, First Also Primary: YES / NO Relationship to student E-mail Primary Phone Number (circle one) Cell / Home / Work Alternative Phone Number (circle one) Cell / Home / Work Additional Contact #2 Last, First Also Primary: YES / NO Relationship to student E-mail Primary Phone Number (circle one) Cell / Home / Work Alternative Phone Number (circle one) Cell / Home / Work Records Information The most recent school this student attended was: School Name A public/district/charter school in AZ City/State A public/district/charter school OUTSIDE AZ Grade level during this enrollment A private or tribal school Status: Active, will attend both schools concurrently* Homeschooling Withdrawn/intends to withdraw No previous school enrollment/other Approximate last day of attendance *Be aware that some schools have policies against allowing students to be enrolled at more than one school at a time. Recognizing the best interests of our students, Sequoia Choice fully supports concurrent enrollment as long as the student is able to meet the academic requirements of both schools. Name(s) of any other schools your student has attended that we should request records from: Has the student been expelled or long-term suspended from a previous school? Yes / No If yes, please explain: Does the student have a medical condition or personal situation that our school should be aware of? How did you hear about Sequoia Choice? Temporary Placement for Special Education Services Has your student ever received Special Education Services? Yes / No If Yes, did your child have an (circle all that apply) IEP / 504 plan / Other: Is the child s IEP (circle one) Current or Expired? Approximate date of IEP Is the child s 504 Plan (circle one) Current or Expired? Approximate date of 504 Plan I give permission for my child to receive special education services: Language Survey Yes / No What is the primary language spoken at the student s home? ENGLISH SPANISH OTHER What is the primary language spoken by the student? ENGLISH SPANISH OTHER What is the language that the student first acquired? ENGLISH SPANISH OTHER
3 Federal Housing Questionnaire This information is gathered for the U.S. Department of Education Impact Aid Grant. Check all boxes that apply: The student resides on federally recognized Indian Lands. The student resides in HUD housing. The student resides in Section 8 housing. The student resides in military housing. The student has a parent who is on active duty in the U.S. military. Branch/Rank School Photo/Video Permissions Policy During the school year, students may be photographed, recorded, or filmed while participating in school programs, field trips, or other activities. Students may also create schoolwork and/or other intellectual property such as artwork, essays, and poetry ( creative work ) as part of the educational process. We love to highlight students on our websites and monthly newsletters, and may seek permission to use student images for brochures or video productions advertising our school. Consent and Release: Sequoia Choice may use, release, and/or publicize my child s image, first name and last initial, or creative work for educational, editorial, or promotional purposes. Unless indicated below, Sequoia Choice will consider participation in school events as consent. I CONSENT to Sequoia Choice s Photo/Video permissions policy I DO NOT consent. The school MAY NOT publish any image, creative work, or reference this student by name in any school publication. Parent/Guardian signature Date Hearing/Vision Screening Permissions Hearing and vision screenings are conducted throughout the school year at academic centers, state testing sites, and by appointment with our main office staff in accordance to Arizona Revised Statues 36.899.01-04. The results of these screenings are gathered and a school administrator submits an annual state report to the Arizona Department of Health services at the end of the school year. Parents are generally notified of their child s results only if the student fails the screening, at which point further consultation and a follow up from your primary care physician, audiologist, or optometrist is recommended. All students are expected to be screened unless their parents sign to OPT OUT of these tests. I WILL ALLOW my student to receive routine vision/hearing screenings by Sequoia Choice. I will make sure my student arrives on time when a screening is scheduled for them. I want to OPT OUT of school hearing/vision screenings for my child. Parent/Guardian signature Date Policies and Expectations I have received and read the Contract of Expectations, Teacher Qualifications Notice, and Privacy Policy (pages 8-11 of this enrollment packet). By signing below, I confirm that the information on this enrollment form is correct, and that I agree to abide by all school policies and expectations, including but not limited to attendance, benchmark and state testing, and academic progress. Parent/Guardian signature Date Student signature Date
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NOTE: Completing this form helps us maintain our Title I status. Personal information is never distributed to third parties. 6 6
NOTE: In addition to signing this page, you must still provide a valid Proof of Residency document that matches the address on the enrollment form. If necessary, please contact the registrar to obtain the Shared Residency form. 7 7
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