STUDENT INFORMATION
First Name
Middle Name
Last Name
Date of Birth
Address
Apt. #
City
State
Zip Code
County of Residence
Phone
School District of Residence
School Attended 2010-2011 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 
Current 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
Guardian 2 First Name
Guardian 2 Middle Name
Guardian 2 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
Sibling 2 Name
Sibling 2 Age
Sibling 2 Current School
   
Sibling 3
Sibling 3 Name
Sibling 3 Age
Sibling 3 Current School
   
Sibling 4
Sibling 4 Name
Sibling 4 Age
Sibling 4 Current School
   
EMERGENCY CONTACT INFORMATION
(other than parent/guardian)
Primary Contact
Emergency Contact First Name
Emergency Contact 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 previously attended
 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 been determined as Gifted
 Yes 
 No 
Has the student been classified by Special Education Services with any of the following disabilities
 Autistic/Autism 
 Hearing impairment 
 Multiple disabilities 
 Emotional disturbance 
 Speech or language impairment 
 Visual impairment (e.g. blindness, etc...) 
 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 
   
2011-2012 Grade Level *
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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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