schoolform - Formstack

	Student Application **Please fill out one application per child
	What school district do you live in?
	Grade entering PCA?
	Name* First Name Last Name
	Address* City State Zip Code
	Gender*
	Birthdate*
	Ethnicity*
	Does your child speak english* yes no
	Parent/Guardian Name* First Name Last Name
	Parent/Guardian Birthdate*
	1st Parent/Guardian Address* City State Zip Code
	Home Phone*
	Cell Phone*
	Work Phone*
	Relationship to Child*
	2nd Parent/Guardian Name* First Name Last Name
	2nd Parent/Guardian Birthdate*
	Cell Phone*
	Home Phone*
	Work Phone
	Place of Employment
	Email*
	Comments

	Emergency Contacts
	Emergency Contact 1 Name First Name Last Name
	Emergency Contact 1: Relationship to Student
	Emergency Contact 1: Phone
	Emergency Contact 2 Name First Name Last Name
	Emergency Contact 2: Relationship to Student
	Emergency Contact 2: Phone

	Prospective Student Information Please fill out all of the information about the student below
	Last school Attended City State Zip Code
	Special Programs Speech Special Education ESL Gifted Other: Other Value
	My Child has siblings . . . . Currently attending PCA Wanting to attend PCA
	Siblings currently attending PCA Please include name and grade
	Siblings would like to attend PCA Please include name and grade

	Confirmation of enrollment The Delaware charter law (Del. C., Title 14, Chapter 5, 506 subsection c) was amended in July 2005. As a result of the amendment to the law, each charter school is required to obtain a written confirmation, signed by a party or guardian of each student that in that student’s initial year of attendance at the charter school that the student will include a statement reading, “I understand that my child is required to remain in this school year” and shall be kept on file at the school and made available for inspection to Department of Education officials or representatives from the public school district in which the student resides. After a student’s initial year of enrollment, it shall be presumed for school district planning purposes only that the student will continue to attend the charter school until completion of that school’s highest grade level and no further written confirmation need be obtained by the charter school.
	I, Parents/Guardians of the above student intend to enroll my child at Providence Creek Academy Charter School for the 2012/2013 school year and acknowledge that I intend for my child to attend this school for the complete school year. I understand that my child is required to remain in this charter school, in the absence of any condition constituting good cause, for at least one school year. Please type your name above

Student Application