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2020-2021 PRE-ENROLLMENT APPLICATION FORM Phone (831) 336-5167 or

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2020-2021 PRE-ENROLLMENT APPLICATION FORM
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 COMPLETE FORM ON BACK
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
Powerschool
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
_Demographics
_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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Completed 17 March 2021

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