STUDENT ENROLLMENT FORM

Sibling Information

Only include siblings currently in school
Name

First Name Sibling Last Name
AGE
GENDER

F M
School
Grade
Name

First Name Sibling Last Name
AGE
GENDER

F M
School
Grade
Name

First Name Sibling Last Name
AGE
GENDER

F M
School
Grade
Name

First Name Sibling Last Name
AGE
GENDER

F M
School
Grade
Please list any additional siblings here.

EMERGENCY CONTACTS - In emergency, parents/guardians will be called 1st. Emergency contacts will be called in the order indicated. Emergency contacts listed have permission to pick up student at school? *

Y N
Parent Initials *

Clear
Emergency Contact 1 *

FIRST NAME CONTACT LAST NAME
Relationship to Student *
City *
State *
PRIMARY LANGUAGE SPOKEN *
Home Phone
Cell Phone *
Emergency Contact 2

FIRST NAME CONTACT LAST NAME
Relationship to Student
City
State
PRIMARY LANGUAGE SPOKEN
Home Phone
Cell Phone
Emergency Contact 3

FIRST NAME CONTACT LAST NAME
Relationship to Student
City
State
PRIMARY LANGUAGE SPOKEN
Home Phone
Cell Phone
Emergency Contact 4

FIRST NAME CONTACT LAST NAME
Relationship to Student
City
State
PRIMARY LANGUAGE SPOKEN
HOME PHONE
CELL PHONE.

Non-Discrimination Notice

Utopian Academy for the Arts recognizes the diversity and worth of all individuals and groups in our society. It is the policy of the Utopian Academy for the Arts that all educational programs, activities and employment will be free of discrimination or harassment on the grounds of race, color, religion, gender, gender identity, sexual orientation, national origin, disability, parental or marital status, or age.

Residency Notice

To be enrolled in the Utopian Academy for the Arts Charter Schools, students must reside full-time in Clayton County with their natural parent(s), Legal guardian(s), or legal custodian(s) Students and their arent(s)/guardian(s)/ custodian(s) must remain full time Clayton County Residents for the entire period of enrollment in the Utopian Academy for the Arts Charter School. For the Purpose of thisa policy, resident is defined as an individual who is a full-time occupant of a dwelling located in Clayton County and who, on any given school day, is likely to be at their stated address when not at work or school.A person who owns property in the county, but does not reside in the county, is not considered a resident for the purpose of this policy. Student enrollment forms, as well as other official documents of the school, must be by signed the natural parent or legal guardian with whom the student resides. Educational decisions concerning the child are reserved for the enrolling parent, although both parents can be involved in the process. If there is disagreement between the two parties, the enrolling parent's decision will be the governing decision.

FalseSwearing Notice (0.C.G.A.16-10-71) (a) A person to whom a lawful oath or affirmation has been administered or who executes a document knowing that it purports to be an acknowledgement of a lawful oath or affirmation commits the offense of false swearing when, in any manner or thing other than a judicial proceeding, he knowingly and willfully makes a false statement. (b) A person convicted of the offense of false swearing shall be punished by fine of not more than $1,000 or by imprisonment for not less than one nor more than five years, or both.

I hereby affirm, by my signature, that I am either the parent or guardian of the student being enrolled. I hereby affirm that I am a FULL TIME resident of Clayton County and the information I have given in this document is, to the best of my knowledge, true and correct. I am that all information provided is true, accurate and up-to-date Any false statement subjects the student to immediate withdrawal.
Parent Signature *

Clear
Date *

Month Day Year
Date
Should be Empty: