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Children’s Success Academy – Enrollment Form

 

Children Success Academy

Phone: 520-799-8403

P. O. Box 11368 Tucson, AZ 85734-1368

Today's Date:

 

Arizona SAIS #:

 

Student’s Full Legal Name:

  Grade Entering:

Home address:

 

Home Phone:

 

 

Apt. Number

 

Sex:

 

 City:

 

State

Zip:

 

Birth Date:

   /      /

Mailing address:

 

  Birth Place:

 

 City:

 

State:      

 

Zip:

 

SS#:

Last school attended:

Grade:

 

District:

 

School Street address:

 City:

 

State:

 

Zip:

 

Phone: (           )           -

Date withdraw/Last day of attendance:

 Emergency Contact:

Relationship:

Phone: (         )              -

Address:

Emergency Contact:

Relationship:

Phone: (           )           -

Address:

Family Physician:

Phone: (           )           -

Address:

  

Last Name

First Name

Student

living with

Has legal

Custody

Place of Employment

Business Phone

Father

 

 

 

 

 

 

Mother

 

 

 

 

 

 

Stepfather

 

 

 

 

 

 

Stepmother

 

 

 

 

 

 

Legal Guardian

 

 

 

 

 

 

Foster Parent

 

 

 

 

 

 

 

** If there is a Divorce or legal separation please provide custody papers

Sisters & Brothers

First Name, Last name (if different)

Age

Grade

School attending

 

 

 

 

 

 

 

 

 

 

 

 

 

Parent/Guardian Signature: ______________________________________________

 

FOR OFFICE USE ONLY

Records requested:

Legal Alert

Medical Alert

  Grade

Code

Date

Records received:

Custody papers on

Immune

 

 

 

Birth Certificate

Other

 

 

 

 
 

Home Language Survey

 What is the first language student learned?        
 What language does student speak most often?        
 What language spoken most often at home?        
 

Race/Ethnic Background (put a check mark by the applicable option )

American Indian/Alaska

African American :

Caucasian:

Pacific Islander or Asian

Hispanic:

Other (please specify)
Mark if applicable and briefly explain:

Gifted Program:

Chronic Illness:

Physically Handicapped:

 

Learning Disabled:

Hearing Handicapped:

Trainable, Mentally Handicapped:

 

Multiple Handicapped:

Speech Handicapped:

Educable, Mentally Handicapped:

 

Visually Handicapped:

Emotionally Handicapped:

Other (please explain):

 

Special Placement in:

Needs help in:

 

 
 

Medical History: Give Dates and Information (put a check mark by the applicable option(s))

Measles:

Mumps:

Convulsive disorder:

Allergy:

Hearing Loss:

Recent ear infection:

Asthma:

Diabetes:

Heart condition:

Chicken pox:

Scoliosis:

T. B. or contact:

Glasses:

Operations:

Daily medication:

Physical Handicap:

PE Restriction:

Others: