STUDENT INFORMATION
*First Name:
*Middle Name:
*Last Name:
Student's Date of Birth:
Select Month
January
February
March
April
May
June
July
August
September
October
November
December
Select Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Select Year
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
Address:
Apt. #:
City:
State:
Zip Code:
County of Residence:
Phone:
School District of Residence:
School Attended 2009-10 School Year:
City of Prior School:
Student's Gender:
Male
Female
Student's Ethnictiy: Is the student Hispanic/Latino?:
Yes
No
Student's Race:
Alaskan Native or Native American
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
2009-10 Grade Level:
This is the ____ time the student has ever entered this grade level.
First Time
Second Time
Third Time
PARENT/GUARDIAN INFORMATION
Who is the legal guardian of this student?
Parent/Guardian 1
First Name:
Middle Name:
Last Name:
Address:
Apt. #:
City:
State:
Zip Code:
Home Phone:
Work Phone:
Cell Phone:
E-mail Address:
Relationship to Student:
Parent/Guardian 2
First Name:
Middle Name:
Last Name:
Address:
Apt. #:
City:
State:
Zip Code:
Home Phone:
Work Phone:
Cell Phone:
E-mail Address:
Relationship to Student:
DOES THE STUDENT HAVE ANY SIBLINGS?
Sibling 1
Name:
Age:
Current School:
Sibling 2
Name:
Age:
Current School:
Sibling 3
Name:
Age:
Current School:
Sibling 4
Name:
Age:
Current School:
EMERGENCY CONTACT INFORMATION
(other than parent/guardian)
Primary Contact
First Name:
Last Name:
Address:
Apt. #:
City:
State:
Zip Code:
Emergency Number:
This is the
Cell
Work
Home
Relationship to Student:
This individual has permission to transport my child in the event of an emergency
Yes
No
Secondary Contact
First Name:
Last Name:
Address:
Apt. #:
City:
State:
Zip Code:
Emergency Number:
This is the
Cell
Work
Home
Relationship to Student:
This individual has permission to transport my child in the event of an emergency
Yes
No
FAMILY & STUDENT INFORMATION
English Proficiency of the student:
Native English Speaker
Fluent English Speaker
Non-English Speaking
Redesignated as Fluent English Proficient
Limited English Proficient/English Language Learner
Status Unknown
Primary Language Spoken at Home:
Arabic
Cantonese
Chinese (non Cantonese)
English
French
French Creole
German
Greek
Hindi
Italian
Japanese
Korean
Persian
Polish
Portuguese
Russian
Spanish
Tagalog
Urdu
Vietnamese
The school the student attended previously can be catergorized as:
Public, in state
Public, out of state
Private, in state
Private, out of state
Original Entry into US school
Located outside of the country
Charter school
Home schooling
Has the student taken a standardized test and been determined "Gifted?"
Yes
No
Has the student been classified by Special Education Services with any of the following disabilities?
(Check all that apply)
Autistic/Autism
Hearing impairment
Multiple disabilities
Emotional disturbance
Speech or language impairment
Visual impairment (e.g. blindness)
Deafness
Mild/Moderate/Severe Disability
Attention Deficit Disorder
Deaf-blindness
Mental retardation
Orthopedic impairment
Specific learning disability
Traumatic brain injury
Other health impairment
Developmental delay
Other
None
Does the student currently have an IEP?
Yes
No
21st Charter School at Gary provides services to all children. If your child as an IEP or 504 plan, please provide a copy to the school so that we can better serve your child's needs.
Fountain Square Academy | 1615 S. Barth Avenue | Indianapolis, IN 46203
Phone: 317-951-1000 | Fax: 317-423-2507 |
FSAnfo@fountainsquareacademy.org
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GEO Foundation
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