Enrollment Form Part 1

*Application School:

*Current Grade -
Please note, early
applications are not
processed. Students
MUST be entering, at
minimum, 6th grade
in the 2012-13 year
to apply at this
time.:

*Grade Applying For:

*Previous/Current
School:

Telephone Number of
Previous/Current
School:

Fax Number of
Previous/Current
School:


	Student Information

*First Name:

*Middle Name:

*Last Name:

*Gender:

Male
Female

*Date of Birth:

/ /

*City of Birth:

*State of Birth:

*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:

- -

Student 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 Line 1:

Home Address Line 2:

*Home Address City:

*Home Address State:

*Home Address Zip:

Mailing Address Line
1:

Mailing Address Line
2:

Mailing Address City:

Mailing Address
State:

Mailing Address Zip:


	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
First Name:

*Parent/Guardian Last
Name:

*Parent/Guardian
Email Address:

*Parent/Guardian
Address Line 1:

Parent/Guardian
Address Line 2:

*Parent/Guardian
Address City:

*Parent/Guardian
Address State:

*Parent/Guardian
Address Zip:

*Parent/Guardian
Relationship:

Parent/Guardian
Employer Name:

Parent/Guardian
Occupation:

Parent/Guardian Work
Phone:

- - x

Parent/Guardian Cell
Phone:

- -

Parent/Guardian Name
of College Attended:

Parent/Guardian
Degree Earned:

2nd Parent/Guardian
First Name:

2nd Parent/Guardian
Last Name:

2nd Parent/Guardian
Email Address:

2nd Parent/Guardian
Address Line 1:

2nd Parent/Guardian
Address Line 2:

2nd Parent/Guardian
Address City:

2nd Parent/Guardian
Address State:

2nd Parent/Guardian
Address Zip:

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 - First
Name:

*Contact 1 - Last
Name:

*Contact 1 -
Relationship to
Student:

Contact 1 - Address:

*Contact 1 - Home
Phone:

- -

*Contact 1 - Work
Phone:

- - x

*Contact 1 - Cell
Phone:

- -

Contact 2 - First
Name:

Contact 2 - Last
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)


	These questions are in compliance with Arizona Administrative Code R7-2-306(B)(1), (2)(A-C)

*What is the primary
language used in the
home regardless of
the language spoken
by the student?:

*What is the language
most often spoken by
the student?:

*What is the language
that the student
first acquired: