Silvies River Student Application

Silvies River Charter School Student Application
Only fill out this form if you are interested in applying for our school. Please make sure your contact information is accurate so we can contact you. When you fill out the form our enrollment specialist will give you a follow up phone call to ensure your interest and verify your information.
HAVE YOU EVER PREVIOUSLY BEEN ENROLLED AS A STUDENT WITH SILVIES RIVER CHARTER SCHOOL OR ARE YOU CURRENTLY A STUDENT WHO IS APPLYING FOR CONTINUED ENROLLMENT IN A NEW YEAR*

YES - I am a PREVIOUS studentYES - I am a CURRENT studentNO - I have NEVER attended SRCS
WHEN WOULD YOU LIKE THIS REQUESTED ENROLLMENT TO BEGIN*

In the Current School Year - 24/25In the Next School Year - 25/26
First and Last Name of Applicant Student*

First NameLast Name
Enter student's Legal Middle name.
Enter Student's Date of Birth*

MonthDayYear
Gender*

MFNon-Binary
Ethnicity*

Hispanic or LatinoNot Hispanic or Latino
Race New federal regulations require that we report Race as well as Ethnicity. Select at least one response (you may select more than one as appropriate)*

WhiteBlackNative AmericanPacific IslanderAsian
Language Spoken at Home (Language of Origin)*

EnglishSpanishRussianChineseJapaneseOther
STREET Address - Please enter the physical address where this student resides.*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Mail Address - Does student receive US Mail at the above address?

YESDifferent Address
Mailing address - Please enter address for receiving mail here.*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone for this applicant*
Does the student have their own Cell Phone?

YESNO
Student's Cell Phone Number
Does the student have their own eMail Address ( If same as Parent, Check NO )

YESNO
Student's eMail address
Please complete as fully as possible
Which School District do you currently reside in
School District where you currently reside*
Select district name from pull down list. If unknown select 'I Do Not Know'...
Are you currently enrolled and attending school in any way including home school*

YESNO
In what school year did you last attend*

20/2119/2019/20 But Withdrew18/1917/1816/17Never AttendedOther
What best describes your current school status*

Attending a public K-12 schoolAttending a private K-12 schoolHome School - RegisteredHome School - Not RegisteredAttending a Virtual School
Last Grade Attended*
Select from list
What Grade Level are you requesting to enroll in at this time*
Select from list
Last School Attended - Name
Name of School
Last School Attended - Location
City and State
Has this student, to your knowledge, ever been provided any of the support services listed Check all that apply.

Special Education (IEP)504 PlanEnglish as a 2nd LanguageMigrant ServicesPhysical Therapy ServicesSpeech and Hearing Services
When and Where Please provide any information you may have about when you last met with a school official and from what school these services were provided.
Does this student applicant have a Brother or Sister currently enrolled in Silvies River Charter School*

NOYES
If Yes. What is the sibling's name
Student Lives with

Both ParentsMotherFatherGrandparent(s)StepparentGuardian / Foster ParentAlone
Is student currently in Foster Care?*

YESNO
What is the primary eMail address to be used for contacting this applicant's parent(s)*
PARENT MILITARY CONNECTION Is one or more parent or guardian a full-time member of the Army, Navy, Air Force, Marine Corps, Coast Guard or full-time National Guard Member. OR Is one or more parent or guardian on active duty for at least 180 days with a military reserve unit*

YESNO
Parent 1 Information
Parent 1 Relationship to Applicant Student
Parent 1 Name

First NameLast Name
Which phone number(s) may we use to contact Parent 1*

Home PhoneCell PhoneWork PhoneNone
Parent 1's Home Phone Number
FParent 1's Cell Phone Number
Parent 1's Work Phone Number
Is Parent 1's eMail address the same as the primary address provided above or different*

SameDifferent
Parent 1's eMail
Is Parent 1's Mailing Address the Same as the applicant student

YESNO
Parent 1's Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent 2 Information
Would you like to add a 2nd parent / guardian's contact information

YESNO
Parent 2's Relationship to Applicant Student
Parent 2's Name

First NameLast Name
Which phone number(s) may be used to contact Parent 2

Home PhoneCell PhoneWork PhoneNone
Parent 2's Home Phone Number
Parent 2's Cell Phone Number
Parent 2's Work Phone Number
Is the Parent 2's eMail address the same as the primary address provided above or different

SameDifferent
Parent 2's eMail
Is Parent 2's Mailing Address the same as the Applicant Student

YESNO
Parent 2's Mailing Address.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Alternate / Emergency Contact
Alternate Contact NAME: Please provide the name of a primary alternate or emergency contact for this student. (Close friend / Relative etc)*
Alternate Contact PHONE*
Other Information: Please enter any other comments and or questions that you might have which would help the registrar and counselor in evaluation of this application.
How did you learn about our program (Check any that apply)

Recommended by a friendRecommended by a school counselorFrom your web siteFrom an add in a local paperFrom a printed flyerFrom FaceBook
Enter Student's Date of Birth*
Enter as MM/DD/YYYY
MonthDayYear
Should be Empty:

Silvies River Charter School Student Application

Only fill out this form if you are interested in applying for our school. Please make sure your contact information is accurate so we can contact you. When you fill out the form our enrollment specialist will give you a follow up phone call to ensure your interest and verify your information.

Please complete as fully as possible

Parent 1 Information

Parent 2 Information

Alternate / Emergency Contact