2021-2022 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:___________
2021-22 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
▢ 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)
