Family Information

Albert Lea Online Academy Student Enrollment Form
Student Enrollment Form
Please select the number of students you need to enroll. *

	First Name	Middle Name	Last Name	Date of Birth	Gender	Grade	Birth Place
Student 1
Student 2
Student 3

	First Name	Middle Name	Last Name	Date of Birth	Gender	Grade	Birth Place
Student 1
Student 2
Student 3
Student 4

	First Name	Middle Name	Last Name	Date of Birth	Gender	Grade	Birth Place
Student 1
Student 2
Student 3
Student 4
Student 5

	First Name	Middle Name	Last Name	Date of Birth	Gender	Grade	Birth Place
Student 1
Student 2
Student 3
Student 4
Student 5
Student 6

Are there any non-school-age children living in the household?*

Student Information*

	Y/N	If yes, where?
Have your children ever attended District 241 (Albert Lea Area Schools)?
Have your children ever attended a Minnesota School Before?

Special Services Information*

	Y/N
Have any of your children received English Language or Bilingual Services?
Is an interpreter needed?
Do any of your children currently have an IEP (Individualized Education Plan) or a 504 Plan?

If yes,

	Student Names
*Please list each student who currently has an IEP and/or 504 plan:

*Kindergarten Only - Preschool Information

	Y/N	If yes, where?
Has your child received preschool screening?
Has your child attended preschool?

Primary Parent/Guardian Information

Person(s) with whom the student resides

Parent/Guardian Information*

	First Name	Last Name	Home Phone	Cell Phone	Work Phone	Relationship to Student	Email Address	Place of Employment
Parent/Guardian 1
Parent/Guardian 2

Address*

	Street Address	City	State	Zip
Home Address
Mailing Address

Do the parent/guardians listed about have full legal rights?*

	Yes	No	Other
Parent/Guardian 1
Parent/Guardian 2

Is there a secondary parent/guardian living in a seperate home who has custodial and/or educational rights?*

Secondary Parent/Guardian Information

If living in a separate home from student. If Secondary Parent/Guardian Information is not applicable, please click "Next" below.

Secondary Parent/Guardian Information

	First Name	Last Name	Home Phone	Cell Phone	Work Phone	Relationship to Student	Email Address	Place of Employment
Secondary Parent/Guardian

Address

	Street Address	City	State	Zip
Home Address
Mailing Address

	Y/N
Can this person legally have contact with the student? (If no, please proive court documentation)
Can this person be legally contacted if necessary? (If no, please proive court documentation)
Does this person have custodial rights? (If no, please proive court documentation)
Does this person have educational rights? (If no, please proive court documentation)
Does this student reside with this person part-time during the school year?

If yes,

More Information

*Please specify:

	Y/N
Should duplicate copies of ALL confidential school mailings be sent to this person? (If no, please proive court documentation)

OR

	Report Cards	Attendance Notes	Discipline Reports	All other general school mailings
Only those selected:

Emergency Contacts

The following person(s) are allowed to pick up my child in my absence.

	First Name	Last Name	Home Phone	Cell Phone	Work Phone	Relationship to Student	Can Student be Release to this Person?
Emergency Contact 1
Emergency Contact 2

Medical Information

Health information will be shared with our Licensed School Nurse who will call to follow-up, if necessary. If your child received their immunizations outside of Minnesota, please provide us with a copy. If you choose not to immunize your child due to medical or conscientious objection, we need the notarized statement on file here at school.

	Y/N	If yes, please explain
Do any of your children need to take any medications while at school? (If yes, please indicate child's name, medication, dosage, and time of day taken)
Do any of your children have any health conditions such as diabetes, severe allergies, asthma, or seizures?

	Y/N
Are your children up-to-date with immunizations?

Family Information

.

	Y/N
Are there any "No Contact" or other legal orders in effect regarding your student(s)? *If yes, you must provide a copy.
Has your family moved within the past 36 months as a result of seasonal or temporary employment of parent in agricultural work?
Do you currently reside with another family, or person other than family, or in a temporary housing facility?
Is this student in Foster Care?
Is this student a military connected youth?
Does this student have an actively deployed parent?

As the parent/guardian of the above mentioned student(s), I am legally qualified to enroll the student(s) in Albert Lea Area Schools.
First Name Last Name

Parent/Guardian Name
Parent/ Guardian Signature *

Clear
Date*

MonthDayYear
Date
Should be Empty: