'24-'25 Online & In Person Classes Enrollment Form

Online & In Person Classes

Enrollment Form
Parent Name

First NameLast Name
Are you legally allowed in CA to make educational decisions about the student?

YesNo
If you are not the biological parent or custodial parent, please submit any POA or court orders to show that you legally are allowed to make educational decisions on behalf of the student.
Parent Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Legal Name

First NameLast Name
Student Preferred Name/Nickname
If they do not use one, please write N/A
Student Birthday

MonthDayYear
Date
Student Current Grade
Does the student have/need an IEP or 504 Plan?

YesNo
If yes, please describe the IEP or 504 Plan
Please submit copy of plan after enrollment approval.
Current School
If homeschooling privately, write PSA

If enrolling for In Person Classes:
Emergency Notification Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Relationship to Student
Please list all adults who are allowed to drop off/pick up student.
Valid, current ID will be needed for pick ups.
Does the Student have any food allergies?

YesNo
If yes, please describe/list foods.
Does the student have any medical conditions/needs?

YesNo
If yes, please describe.
Will the student require any medication to be stored on site and/or administered during the time that the student will be enrolled?

YesNo
If yes, please describe.

Registration Fee
The registration fee is $25 per family. This cost is not covered by charter school funds and must be paid by the family.
How will you pay the registration fee?

Charter Info
Are you using charter school funds?

Yes, Granite MountainYes, IEM Schools (Shutter, Ocean Grove, Sky Mountain)Yes, Sun Coast PrepYes, Sage OakYes, Elite Academic AcademyYes, but my school is not listedNo, My school is not listedNo, I am not using a charter school
If school is not listed, what school are you currently with?
If we are not a current vendor with your charter school, please contact your teacher to add us as a vendor. If we become a vendor with your school, there will be no out of pocket costs to you each month.

Your school will need the following info:

34th St Prep Academy
15356 La Paz Dr #4
Victorville, CA 92395
34thstreetprep@gmail.com
442-866-9022

Breanna Humes - Owner
Current Charter Teacher
Charter Teacher email.
example@example.com
Should be Empty:

Online & In Person Classes