25-26 Charter School Student Enrollment Notification Form

Charter School Student Enrollment Notification Form
Warning: A child enrolled in another public school, or a nonpublic or private school cannot, at the same time, enroll in a charter school.

Name of Charter School: Pennwood Cyber Charter School

Address: 2951 Whiteford Road, Suite 204,York, PA 17402

Charter School Contact Person: Leslie VanHart, Business Manager

Telephone: 717-208-4463

Email: Pennwood-registrar@pennwood.connectionsacademy.org
Student Information
Name*

First NameLast Name
MI*
Home Address*
City*
State*
Zip*
County*
Telephone*
Mailing Address (if different from home address)
City
State
Zip
Date of Birth*

MonthDayYear
Date
Age*
School District of Residence and Former School Information
Current School District of Residence*
Former School Information (Other Than Pre-School)*

Public SchoolCharter SchoolHome SchoolNonpublic/Private School
Student Not Enrolled in School Preceding Enrollment in Charter School Because*

Entering KindergartenRe-Enrolling DropoutOther
Name of Former School
Address of Former School
Previous Grade
Withdrawal Date from Former school

MonthDayYear
Date
Was your Child receiving Special Education Services Based on an IEP?*

YesNo
If yes, do you have the Child’s Special Education Records (IEP)?*

YesNo
Parent/Guardian Information
Child lives with:*

Both ParentsBoth Parents AlternatelyParent#1 OnlyParent #2 OnlyLegal GuardianFoster ParentsOther Adult
Complete Parent/Guardian Name and Address Information as Applicable:
Parent #1 Name*
Address*
City*
State*
Zip*
Home Telephone*
Email Address*
example@example.com
Parent #2 Name
Address
City
State
Zip
Home Telephone
Email Address
example@example.com
If the student is not living with parents, please complete this section:
If the student is not living with parents, please complete this section

GuardianFoster ParentOther Adult
Name
Address
City
State
Zip
My signature on this form indicates my decision to have my child attend the charter school named on page 1 of this form and signifies my request that appropriate school records be forwarded from the school district to the charter school. My signature also certifies that my child is not, and will not be, enrolled in another public school, a nonpublic school or a private school at the same time he or she is enrolled in this charter school.
Signature*

Powered by Jotform SignClear
Date*

MonthDayYear
Date
Should be Empty:

Charter School Student Enrollment Notification Form

Student Information

School District of Residence and Former School Information

Parent/Guardian Information

If the student is not living with parents, please complete this section: