Enrollment Form Part 1

*Application Year:

*Grade:

*Application School:


	Student Information

*First Name:

Middle Name:

*Last Name:

Also goes by
(Nickname):

*Gender:

Male
Female

*Date of Birth:

/ /

*Place of Birth
(City, State):

*Previous/Current
School:

*Current Grade:

Address of
Previous/Current
School:

*Is student Hispanic
or Latino?:

Yes
No

*Ethnicity:

American Indian or Alaskan Native (if American Indian, please list Tribal Affiliation under "other")

Asian

Black or African American

Native Hawaiian or other Pacific Islander

White

Other:

*Home Phone:

- -

Email Address:

*Student Lives With:

Custody
Considerations:

(chars left: 500)

Relation and name of
current TPA students
and/or alumni (if
applicable):

(chars left: 300)

*Home Address, City,
State, Zip:

(chars left: 300)

Mailing Address,
City, State, Zip:

(chars left: 300)


	Record of Prior Special School Programs

*Special Programs
Status:

My child HAS NOT participated in any special program.
My child HAS participated in SPECIAL EDUCATION.

Special Programs (If
Applicable):

Speech/Language Therapy
Special Education/IEP
Section 504

Please explain any
special programs
and/or help your
child has received
or may need (if
applicable):

(chars left: 1000)


	Parent Information

*Parent/Guardian Last
Name, First Name:

Parent/Guardian
Email Address:

*Parent/Guardian
Address:

*Parent/Guardian
Relationship:

Employer Name /
Occupation:

Parent/Guardian Work
Phone:

- - x

Parent/Guardian Cell
Phone:

- -

2nd Parent/Guardian
Last Name, First
Name:

2nd Parent/Guardian
Email Address:

2nd Parent/Guardian
Address:

2nd Parent/Guardian
Relationship:

2nd Parent/Guardian
Work Phone:

- - x

2nd Parent/Guardian
Cell Phone:

- -


	Emergency Contact Information

*Authorized to be
contacted and/or
transport my student
if I cannot be
reached:

Contact 1 - Last
Name, First Name:

Contact 1 -
Relationship to
Student:

Contact 1 - Address:

Contact 1 - Home
Phone:

- -

Contact 1 - Work
Phone:

- - x

Contact 1 - Cell
Phone:

- -

Contact 2 - Last
Name, First Name:

Contact 2 -
Relationship to
Student:

Contact 2 - Address:

Contact 2 - Home
Phone:

- -

Contact 2 - Work
Phone:

- - x

Contact 2 - Cell
Phone:

- -


	Student Health Information

*Name of Doctor:

*Doctor Phone Number:

- -

Name of Hospital:

Describe any
allergies, asthma,
hearing, vision,
medications or other
health related
concerns:

(chars left: 300)

Describe any
conditions that
would restrict the
student's ability to
participate in
sports or Physical
Education:

(chars left: 300)

Describe any
handicapping
conditions or
Special Education
designations the
school should be
aware of:

(chars left: 300)


	TPA Family Directory

*Please indicate
whether you wish to
have your family's
address and phone
number published in
the TPA Family
Directory. The
directory
facilitates academic
and social life at
the school between
families and is not
to be used for any
other purpose:

Yes
No

*Please indicate
whether you wish to
have your family
email address used
by coaches or the
Parent Organization:

Yes
No

*IMAGE RELEASE: From
time to time,
reporters visit the
school to produce
articles aand video
clips on TPA. Please
indicate whether you
wish to have your
child appear in
photos that may be
published in the
newspaper,
television or TPA
website:

Yes
No


	This question is in compliance with A.R.S. 15-756. Identification of English Language Learners

*Responses to this
statement will be
used to determine
whether your child
will be assessed for
English Language
Proficiency. What is
the primary language
of the student?
(Answer with the
language used most
often by the
student.):