Mail or fax to: Registrar, Charter Office, 325 Marion Ave.
Ben Lomond, CA 95005
Phone (831) 336-5167 or Fax (831) 336-0131
Email to: jhendricks@slvusd.org
If you have any questions, please call (831) 336-5167
QH Homeschool K-5 (6-8)
Fall Creek Homeschool K-5 (6-8)
Mountain I/S K-5 (in Soquel)
Coast Redwood Middle School 6-8
Coast Redwood High School 9-12
QH Integrated Arts 6-8*
Nature Academ 6-8*
Lottery application required
IMPORTANT INFORMATION: Submission of this application does not constitute enorollment. It is
requesting an appointment with a teacher, from the program requested, in order to confirm program specifics,
expectations, and discuss start date. Do not disenroll from your current school until confirmation from our registrar!
Parent/Guardian #1 (Primary Contact)
Parent/Guardian #2
Name (Last, First): __________________________________________ ____________________________________________
Primary Phone # (_____)____________________________________ (_____)______________________________________
Secondary Phone # (_____)__________________________________ (_____)______________________________________
E-mail Address: ____________________________________________ _________________________________________________
College Graduate Graduate Degree or Higher Decline to State
Is either parent/guardian on active duty in the US armed forces? ☐ Army ☐ Navy ☐Air Force ☐Marine Corps
Please check the program your applying for:
Student Legal Name:______________________________________________________________________________________
Student's Physical Address:________________________________________________City_______________ Zip:____________
Student's Mailing Address: ___________________________________________City____________________ Zip:____________
Todays date:___________
2020-21 Grade level:______________
Gender: Male Female Non-binary Legal Gender:______
(Last) (First) (Middle) (Prefered Name)
Street (No P.O. Box)
Previous School Information
Previous School:________________________________Address/Registrar Phone # (Required):_________________________
Previous Retention? Yes/No If yes, what grade?_____
Birth Date: ____________
School District of Residence:______________________________________________County of residence:_________________
Has a sibling in Charter? Yes / No Name:_______________________________ Program:__________________
Parent Education Level:
Not a High School Graduate High School Graduate Some College or AA Degree
DOCUMENTS required to be submitted along with the Pre-Enrollment Application form:
(Please attach/fax required documents with this application. If received without will be returned and must be resubmitted.)
Required for all applicants:
Proof of Age Proof of Address
Copy of Vaccine Record
Copy of IEP or 504 as mentioned on next page
Caregiver Authorization Affidavit (If person enrolling
student is NOT the parent or legal guardian)
Additional for K-1st grades :
Heath Exam Form
Oral Heatlh Exam or Waivor
High School Level:
Transcript copy
(Check all attached)
Does Student have an active IEP or 504? ___________ (If Yes, please provide copy of IEP or 504)
If your child does not have an IEP, but was evaluated for special education, enclose a copy of all assessment reports.
Additional Student Information
Parent/Guardian Signature: _____________________________________
Date: _______________
I acknowledge that enrollment with the SLVUSD Charter School is voluntary.
For Office Use Only
G Dox Other
_Enroll new student acct
_Vax _Wailist _Online Reg. _Med. Info
_State/Province>Calpads Student Info
_Special Prog(2) _Addlist _Prog Roster & Email
_State/Province>Calpads Guardian Info
_(SpED) _Enroll Spreadsheet _Req CUM
_Transcript _>By grade
_Scheduling Set-up (nxt scl)
_Email(3) _FTE/Prog enroll
_Modify Sched(add Teacher)
_PS Access
_Transfer Info>date(District)
Proof of Age
Proof of Address
ELL: Language: ________________________________ Homeless: _________________________________
Medical Issues: ________________________________ Medical Forms given: Yes / No
Custody Issues: Yes / No Court Papers received: Yes / No
Special Health Considerations: ____________________________________________________________________
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