Student Enrollment & Intake Form
The Learning Village Hub
Program Interest
Which program are you interested in?
*
Summer School
GED Preparation Program
Night School
Credit Recovery Support
Tutoring
Workforce Readiness Program
Entrepreneurship Program
Online Learning
Microschool Program *
Homeschool Support
Other
*Would you be interested in:
Full-Time Microschool
Part-Time Microschool
Hybrid Learning
Homeschool Enrichment
Student Information
Student Full Name
*
Preferred Name
Date of Birth
*
Age
*
Grade Level
*
Current School
*
Current Educational Status
*
Public School
Charter School
Homeschool
Online School
Not Currently Enrolled
GED Candidate
Student Email (if applicable)
Student Phone (if applicable)
Parent / Guardian Information
Parent / Guardian Name
*
Relationship to Student
*
Phone Number
*
Email Address
*
Preferred Contact Method
*
Phone
Text
Email
Emergency Contact Name (Main)
*
Emergency Contact Phone (Main)
*
Emergency Contact Name (Secondary)
*
Emergency Contact Phone (Secondary)
*
Guardianship Verification
Are you the student's legal parent or legal guardian?
*
Yes
No *
Other
*If no, please explain:
Do you have legal documentation supporting guardianship?
Yes
No
Not Applicable
Upload Guardianship Documentation
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ESA Information
Is the student currently enrolled in Arizona ESA?
Yes
No
Application Pending
Unsure/Need Help
ESA Student ID
How will tuition/services be paid?
ESA
Private Pay
Scholarship Request
Other
Academic Profile
Which areas need support? (Selelct all that apply)
Reading
Writing
Math
Science
Social Studies
Study Skills
GED Preparation
Credit Recovery
Test Preperation
What are the student's greatest strengths?
What academic challenges are they currently facing?
Student Support Information
Has the student ever received:
*
IEP
504 Plan
Tutoring
Speech Services
Occupational Therapy
Counseling Services
None
Are you interested in learning about scholarships, grants, or financial assistance opportunities?
Yes
No
Type option 3
Type option 4
Wellness & Success Supports
To better support students, please check any areas where support may be beneficial:
Organization
Time Management
Motivation
Focus/Attention
Anxiety/Stress
Emotional Regulation
Career Planning
Life Skills
Not Applicable
Anything else we should know?
Community Support & Resources
This information helps us identify scholarships, grants, and community resources.
Student identifies as:
*
Foster Youth
Kinship Placement
Young Parent
Working Student
First Generation Student
Native American / Tribal Community Member
English Language Learner
Military Family
Prefer Not To Answer
Family & Community Involvement
Would you be interested in supporting The Learning Village Hub in any of the following ways?
Volunteer
Mentoring Students
Guest Speaker
Career Exploration
Internship Opportunities
Event Support
Not At This Time
Program Goals
What are your goals for participating in this program?
Improve Grades
Credit Recovery
GED Completion
Graduate High School
College Preparation
Career Readiness
Entrepreneurship Skills
Academic Confidence
Other
Technology Access
Does the student have access to:
Computer/Laptop?
Yes
No
Internet Access?
Yes
No
Reliable Transportation?
Yes
No
Photo & Media Release
I authorize The Learning Village Hub and participating entities to use photographs or videos for educational and promotional purposes.
Yes
No
Why Learning Village Hub?
What attracted you to The Learning Village Hub and what are you hoping your student gains from this experience?
How did you hear about us?
Facebook
Instagram
Friend/Family
Community Event
Referral
Website
Other
Parent/Guardian Acknowledgment
I certify that the information provided is accurate and complete to the best of my knowledge.
Parent/Guardian Signature
Date
-
Month
-
Day
Year
Date
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