OPEN ENROLLMENT 2

Student Name

First NameMiddle NameLast Name

Incoming Grade Level

Student Date of Birth

Date

Primary Phone Number

Please enter a valid phone number.

Call Connection Type

Work PhoneMessage Phone

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@gmail.com

The above-named student:

Resides outside the School District; orResides within the School District

Present school of attendance

School . District .

Request assignment to

School

Does your student have a sibling currently attending Globe Unified School District#1?

YesNo

Name of sibling

Current grade level of sibling

Educational Needs - to help us determine our capacity to serve your child, please provide the following information: Has your student been enrolled in or in need of any Gifted services?

YesNo

Has your student ever been considered for retention?

YesNo

Special Education Service Needs – the following questions help us to determine our capacity to serve your child. If you have questions please contact Student Services at 928-402-6070.

Has the student ever had an Individualized Education Program (IEP) or a 504 plan?

YesNo

Has the student received any special services but does not have an IEP?

YesNo

Has the student ever been recommended for special education services?

YesNo

Has the student ever been evaluated for special education services?

YesNo

Other Service Needs

Does the student have any chronic health issues that might require special nursing and/or health services?

YesNo

If yes, please explain

Student Background Information – Globe Unified School District may refuse to admit any pupil who has been expelled from another educational institution or who is in the process of being expelled from another educational institution.

Within the past 24 months, has your student been expelled, long-term suspended or placed on a formal behavior plan from any school or school district?

YesNo

Within the past 24 months, has your student withdrawn from a school or school district because of an imminent or potential expulsion or an imminent or potential suspension?

YesNo

Within the past 24 months, has your student not been in full compliance with any condition imposed as disciplinary action or imposed in lieu of disciplinary action by a school or school district?

YesNo

Within the past 24 months, has your student been adjudicated a delinquent or been convicted of a crime?

YesNo

Within the past 24 months, has your student no been in full compliance with any condition imposed by a juvenile court?

YesNo

Within the past 24 months, has your student had a record of excessive absences,truancies, or tardies (10 or more)?

YesNo

If you answered Yes to any of the above questions, please explain

Attestation:

I attest that this student is in good standing at his/her current and previous schools and is eligible to return to such school.

YesNo

I further attest to the truthfulness and accuracy of the information provided in this application form. I understand that false or misleading information may result in the denial of this Open Enrollment application form or the revocation of the student’s status as an Open Enrollment student.

YesNo

If my child is accepted, I affirm that my child will abide by the rules,standards, conditions and policies of the school and the District.

YesNo

If you answered NO to any of the above questions, please explain:

Note: The following conditions apply to the open-enrollment program:

1. An open enrollment application must be completed and submitted.

2. Enrollment is subject to the capacity limit established for the school and/or its grade levels/program and, in the case of a special needs student, required services.

3. Within one month of submitting the open enrollment application, the parent or legal guardian will be notified in writing whether the application has been accepted, rejected, or placed on a waiting list.

4. Transportation for the student may be the responsibility of the parent or legal guardian.

5. Providing false information on this form may result in the application being denied or admission being revoked.

Parent/Guardian Information

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Phone Number

Please enter a valid phone number.

Is either parent or legal guardian an employee of Globe Unified School District#1?

YesNo

The signatory affirms that the student will abide by the rules, standards, and policies of the school and the District if enrolled.

Signature of Parent or Legal Guardian

Date