Enrollment Form

La Vida Independent Study Charter School

P. O. Box 1461

Ukiah, CA 95482

http://www.lavidaschool.org/

 

Student?s Name:                                                                                                         Date of Birth:                                  

Please Print Clearly   First                       Middle                         Last

 

Kindergarten & 1st Grade Parents California Law requires tat all incoming Kindergarten students have a birth certificate, and all 1st grade students to have a comprehensive health exam (CHDPP). Kindergarten and 1st grade need current immunization before enrolling in school. c Birth Certificate received (attached copy) CHDPP Exam report            c Received              c Waiver Immunization record           c Record on File    c Waiver on File

 

Gender:                                   Age:                             Grade:                         Student ID#                                                                                                                                                                                                    (School Use Only)

Student?s Social Security #                 -           -                       City/State of Birth                                                     

Nickname?                                          Other Last Name Used?                                                                                

Mailing Address:                                                                                                                                                        

Physical Address:                                                                                                                                                       

Specific Directions to Home:                                                                                                                                                                                                                                                                                                                         

Name of Last School Attended:                                                                                                                                  

County of Residence:                                                 

Father?s Name:                                                                                   Home Telephone:                                          

Employer:                                                                                            Work Telephone:                                          

Mother?s Name:                                                                                  Home Telephone:                                          

Employer:                                                                                            Work Telephone:                                          

Language:

c English Only          c English Fluent        c English Limited      c Other:                                                        

Student Lives with (check one): 

c Both Parents           c Mother       c Father         c Other:                                       c Student is Foster Child

Please List Other Family Members Living at Home:

Name	Gender	Date of Birth	Relationship to Student

(over please)

 

Is this student experiencing learning difficulties?        c Yes  c No

 

Is this student experiencing behavior difficulties?       c Yes  c No

 

Attendance:      c Regular       c Poor                       c Inconsistent

Relationship with adults:         c Positive                   c Accepted     c Negative

Motor coordination:                c Above Average       c Average      c Poor          c Very Poor

Pupil regularly displays the following behavior: (Please check.)

            c Hyperactivity          c Insecurity              c Aggression            c Frustration

            c Apathy                    c Showing Off          c Defiance                c Trying hard

            c Dependability         c Nail biting              c Destructiveness      c Fantasy

            c Indifference            c Crying                   c Tantrums               c Moodiness

            c Facial ties               c Tattling                  c Bad language          c Cheerfulness

            c Cooperativeness     c Stealing                  c Withdrawal            c Fearfulness

 

Known problem of:     c Vision         c Hearing      c Speech

 

1. Was your child in any special education classes?                    c Yes c No 
2. Was your child in any small group classes?                            c Yes c No 
3. Was your child in any RST or Special Day Classes? c Yes             c No 
4. Does your child have a current IEP available?                         c Yes             c No 

If your answer was Yes to any of the above questions, what was the special education teacher?s name?

                                                                                                                                      

What was the name and location of the school?

                                                                                                                                      

If your child was in special education, please call this to the attention of the office staff or teacher so the necessary procedures can be started as soon as possible.

 

Has student ever been expelled from a school:

c Yes             No c

If yes, please provide Date of Expulsion and briefly explain the circumstances.                                                                                                                                                                                                                                                                                                                                      

 

Legal Restrictions/Custody Issues?

            c Yes             No c  If yes, a current signed court order must be provided to the school.

1. 1.     I understand that it is my responsibility to pick up my child from school when he/she is ill my designated temporary care providers are not able to do so.  c Yes No c 
2. 2.     I understand the school does not provide medical or accident insurance for individual students.
     c Yes      No c             
3. 3.     I grant permission for my child to attend school sponsored local field/study trips. (Permission slips will be sent home only for non local field/study trips)      c Yes      No c

 

                                                                                                                                                                                   

Signature of Parent/Guardian                                                                                                  Date

 

 

Demographics required for STAR testing:

 

Ethnic Background: Please indicate one of the following: c Caucasian c Black cHispanic c American Indian c Filipino c Chinese c Japanese cKorean cVietnamese c Laotian c Cambodian c Other Asian c Hawaiian c Guamanian c Samoan c Other Pacific Islander c Other

*Please note: The school will be charged an additional fee for STAR tests if this information is not provided.

 

                                   

Parents Highest Level of Education: Mother:                                                  Father:                                               

 

Information requested but not required:

Participant in CAL Works program?   c Yes            No c 

(The school may be eligible for additional funding for students whose guardians are participants in CAL Works programs.)