application for enrollment

Highland Free School

Application for Admission

510 South Highland Avenue .

Tucson, Arizona 85719

(520) 623-0104
Student's Name *
For which school year is the student applying?
Entering Grade Level*
Student's Sex*
Student's Birth Date*

MonthDayYear
Date
Student's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student's Home Phone Number
Who is the primary caretaker/guardian?*
Name of Parent 1 *
Parent 1- Home Address (if different from child)
Parent 1- Email Address*
example@example.com
Parent 1- Phone Number*
Parent 1- Employer
Parent 1- Work Contact Phone Number
Name of Parent 2
Parent 2- Home Address (if different from child)
Parent 2- Phone Number
Parent 2- Email Address
example@example.com
Parent 2- Employer
Parent 2- Work Contact Number
Previous School Attended*
City and State of Previous School Attended (If no previous school, please note none or NA)*
Last Grade Attended*
Last Date of Attendance (at previous school)

MonthDayYear
Date
Reason for Withdrawal
Has the child ever been expelled from school or is pending expulsion?*
(If yes, please explain)
Has the child ever been enrolled in or tested for any of the following? [check all that apply]*

NoSpecial EducationGifted ProgramELL/SEL/LEP [English Language Learner]Other
Does the child currently have an I.E.P. or 504 Plan?
If your child has an IEP or 504 Plan, please describe the program(s), special need(s) and/or required accommodation(s).
Does the child have a medical condition for which special accommodations must be provided? If so, please explain and list accommodations. *
The Arizona & U.S. Departments of Education require the following information for census and funding purposes. Note: This information is needed for funding and reporting purposes. Your answers are strictly confidential.
List the number of family members in household (include all members in the household that the guardian(s) are financially responsible for).*
Please list the names and ages of the people included in the count above.*
Please list the total annual household income. [This is for grant purposes only.]*
Military Student Identifier (if applicable)
The following question is intended to address the McKinney-Vento Act 42 U.S.C. 11435. The answers to this residency information help to determine the services the student may be eligible to receive. Where is the student currently living?*

In permanent housingIn a car, park, bus, train, or campsiteWith another family or other person because of loss of housing or as a result of economic hardshipIn a shelterIn a hotel/motelOther
[Click here for more information regarding the Rights of Homeless Students.]
What is the student's race? (mark all that apply)

American Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhite
Is the student Hispanic or Latino?
Home Language Survey

The responses to the following three questions are used by the school to provide the most appropriate instructional programs and services for the student. The answers below will determine if a student will take the Arizona English Language Learner Assessment (AZELLA). Please respond to each of the three questions as accurately as possible. If you need to correct any of your responses, this must be done before the student takes the AZELLA Placement Test.
What is the Primary Language used in home regardless of the language spoken by the student? *
What is the language most often spoke by the student?*
What is the language that the student first acquired?*
At the time of enrollment, a charter school must notify the person enrolling the pupil in writing that within thirty days the person must provide one of the following: 1. A certified copy of the pupil's birth certificate. 2. Other reliable proof of the pupil's identity and age, including the pupil's baptismal certificate,an application for a social security number or original school registration records and an affidavit explaining the inability to provide a copy of the birth certificate. 3. A letter from the authorized representative of an agency having custody of the pupil pursuantto title 8, chapter 2 certifying that the pupil has been placed in the custody of the agency asprescribed by law.
Signature of Guardian(s)*

Clear
Full Name of Signing Guardian *

First NameLast Name
Date

MonthDayYear
Date
Thank you for applying to Highland Free School.
Should be Empty: