The Dropout Prevention and Reengagement Academy (DORA) Enrollment Form

The Dropout Prevention and Reengagement Academy (DORA) Enrollment Form

Include full legal names for parents & emergency contacts. Include complete addresses & phone numbers
Student's Full Legal Name Name

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Gender
Birth Place

CityStateCountry
Student's Primary Language Spoken at Home
Ethnic Heritage (Optional): (Check all that apply):

Native AmericanAsianAfrican AmericanHispanicWhiteOther/multi-racial
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you living in a home with multiple families?

YesNo
Student E-mail
example@example.com
Home Telephone Number:
How many credits have you completed?
What is the last school you attended?
Last date of school attendance:

MonthDayYear
Date
What is your last grade level completed?
Are you interested in pursuing your High School Diploma or GED?

High School DiplomaGED
Who is student living with? (*custody papers required)

Both ParentsMother/Step-FatherMother OnlyFather/Step-MotherFather Only* Grandparents* Legal Guardian* Foster/Group HouseOther (please specify below)
If you selected other for the above question, please specify:
Father/Guardian

First NameMiddle NameLast Name
Father/Guardian E-mail
example@example.com
Father/Guardian Work Number:
Mother/Guardian

First NameMiddle NameLast Name
Mother/Guardian E-mail
example@example.com
Mother/Guardian Work Number:
Every effort will be made to contact parent/guardian in an emergency. In case parent/guardian is not available, please list 1 other person tocontact in case of emergency.
Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Relationship to Student
Parent/Guardian Signature

Clear
Parent/Guardian Printed Name
Relationship to Student
Who referred you to DORA?
Preferred Case Manager
Please leave these questions below blank for internal processing.

Basic Skills Deficient Assessment
Assessment Tool Used:
Date Assessment Completed:
Reading Score (grade level):

123456789101112
Math Score (grade level):

123456789101112
Pre-Test Reading Raw Score:
Pre-Test Math Raw Score:
POST-Test Reading Raw Score:
POST-Test Math Raw Score:
Should be Empty:

The Dropout Prevention and Reengagement Academy (DORA) Enrollment Form

Every effort will be made to contact parent/guardian in an emergency. In case parent/guardian is not available, please list 1 other person tocontact in case of emergency.

Please leave these questions below blank for internal processing.