Armadillo Technical Institute
Your free public charter high school inspiring thoughtful individual choices in learning and growth
Student Enrollment Information
Student Photo (preferred but optional)
Student Legal Name
*
First Name
Middle Name
Last Name
Preferred Name (What does this student like to be called?)
Date of Birth
*
-
Month
-
Day
Year
mm-dd-yyyy
Gender Identity
*
X / Intersex
F / Female
M / Male
Preferred Pronouns
they/them/theirs
she/her/hers
he/him/his
How does your student identify? (Choose all that apply)
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Hispanic / Latinx
Black / African American
Asian
Caucasian
Prefer not to answer
If this student is a registered member of an American Indian / Native American Tribe, please provide their CDIB/membership number
Student Social Security Number
Example: xxx-xx-xxx
Physical Address
*
Street Address
City
State
Zip
Province
Mailing Address
*
Street Address
City
State
Zip
Province
Student Phone Number
-
Area Code
Phone Number
Grade in 2020-2021
*
Grade 9
Grade 10
Grade 11
Grade 12
Birth Place
*
City, State, Country
Name of Last School Attended Before ATI
*
School Name / Dates Attended / City (Hilltop High School / Jan 2018-June 2019 / Flubber, OR)
Last School Year Attended
*
2019-2020
2018-2019
2017-2018
2016-2017
2015-2016
2014-2015
2013-2014
2012-2023
2011-2012
1st Date Attended School in the United States of America
*
-
Month
-
Day
Year
mm-dd-yyyy
Ever attended a school in the Phoenix-Talent School District?
*
Yes
No
Is your student currently under suspension or expulsion from their last school?
*
Yes - Suspension
Yes - Expulsion
No - my child is not currently suspended or expelled from school
Does this student have any of these service or support plans? (Choose all that apply)
*
IEP for Special Education Services
504 Plan for learning accommodations for a documented disability
Medical Plan (safety protocols for a medical condition)
This student has no school based support plans
Please provide the name and organization of any other people such as case workers or parole officers who could help support this student.
Name - Organization
Medical conditions or medications TAKEN AT SCHOOL (examples: diabetes, allergic reactions, asthma, seizures, prescription medication, over the counter medication)
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Guardian & Emergency Contact Information
Guardian 1 (or legal adult advocate)
*
First Name
Middle Name
Last Name
Suffix
Relationship to Student
*
Email
*
Example: mark.armenta@gmail.com
Phone Number (Calls - Required For Emergencies)
*
-
Area Code
Phone Number
Phone Number (Texts)
-
Area Code
Phone Number
Please select all that apply for Guardian 1
*
Approved to pick up student
Student lives with this guardian at least part time
Should receive attendance notifications
Should receive school news and announcements
What is the most effective way to reach Guardian 1?
*
Phone call
Text
Email
Mail
Guardian 2 (leave blank if not applicable)
First Name
Middle Name
Last Name
Suffix
Relationship to Student
Email
Example: mark.armenta@gmail.com
Phone Number (Calls - Required For Emergencies)
-
Area Code
Phone Number
Phone Number (Texts)
-
Area Code
Phone Number
Please select all that apply for Guardian 2
Approved to pick up student
Student lives with this guardian at least part time
Should receive attendance notifications
Should receive school news and announcements
What is the most effective way to reach Guardian 2?
Phone call
Text
Email
Mail
Guardian 3 (leave blank if not applicable)
First Name
Middle Name
Last Name
Suffix
Relationship to Student
Email
Example: mark.armenta@gmail.com
Phone Number (Calls - Required For Emergencies for at least one guardian)
-
Area Code
Phone Number
Phone Number (Texts)
-
Area Code
Phone Number
Please select all that apply for Guardian 3
Approved to pick up student
Student lives with this guardian at least part time
Should receive attendance notifications
Should receive school news and announcements
What is the most effective way to reach Guardian 3?
Phone call
Text
Email
Mail
Emergency Contact #1
*
First Name
Last Name
Emergency Contact #1 - Phone
*
-
Area Code
Phone Number
Emergency Contact #2
First Name
Last Name
Emergency Contact #2 - Phone
-
Area Code
Phone Number
Health Care Provider (Name / Phone)
*
Physician Name / XXX-XXX-XXXX
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Waivers & Agreements
By checking each box and signing below, the authorizer agrees to each statement and to the use of an electronic signature as their legal representation on this document.
ENROLLING GUARDIAN AUTHORIZATION: I assure that, to the best of my knowledge, all information provided on this form is accurate and complete, and that I am authorized to provide such information and enroll the student listed on this form. (Signature below)
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