Charter School Student Enrollment Notification Form For School Year
2016 - 2017
Change of Address
Warning: A child enrolled in another public school or a nonpublic or private school cannot, at the same time, enroll in a charter school.
Name of Charter School:
Lehigh Valley Academy Regional Charter School
Address:
1560 Valley Center Parkway, Suite #200 Bethlehem, PA 18017
Charter School Contact Person: Telephone:
Mrs. Susan Mauser Email (610) 866-9660 Address:
[email protected]
I. Student Information: Last Name: Home Address: City:
First Name:
MI:
State:
County: Date Of Birth: Ethnicity (Please Check):
Telephone: Age:
Zip Code: Gender:
( )M ( )F
__ Amer. Indian/Alaskan __ Asian __ Pac. Islander __ Black __ Hispanic __White __ Multi
II. School District of Residence and Former School Information School District of Residence: Former School Information (Other Than Pre-School): Public School Charter School
Home School
Nonpublic School
Student Not Enrolled in School Preceding Enrollment in Charter School Because: Entering Kindergarten Re-Enrolling Dropout Other Name of Former School: Address of Former School: City, State Zip Code Previous Grade: Withdrawal Date From Former School: Was Your Child Receiving Special Education Services Based On An IEP?
Yes
No
If Yes, Do You Have The Child’s Special Education Records (IEP)?
Yes
No
Medical Assistance (Access) Number, if applicable. ______________ Page 1 of Charter School Student Enrollment Notification Form PDE 2/2008 Instructions for this can be found at www.pde.state.pa.us. Under the K-12 Schools folder, click on Public Schools, then Charter School, then Reporting.
III. Parent/Guardian Information: Child Lives With:
Both Parents Legal Guardian Special Custodial Court Instructions: (If Yes, Please Provide a Copy of Court Order.)
Both Parents Alternately Foster Parents
Mother Only Other Adult
Yes
No
Father Only
Complete Parent/Guardian Name and Address Information As Applicable Father’s Name Address: City: Home Telephone: Cellular Phone: Mother’s Name Address: City: Home Telephone: Cellular Phone:
State: Work Telephone:
Zip Code:
State: Work Telephone:
Zip Code:
If The Student Is Not Living With Parents, Please Complete This Section. Guardian’s Name Name: Address: City:
Or
Foster Parent’s Name
Or
Other Adult Name
State:
Zip Code:
My signature on this form indicates my decision to have my child attend the charter school named on page 1 of this form and signifies my request that appropriate school records be forwarded from the school district to the charter school. My signature also certifies that my child is not, and will not be, enrolled in another public school, a nonpublic school or a private school at the same time he or she is enrolled in this charter school.
Signature of Parent/Guardian:
Date:
IV. To Be Completed By Charter School: Immunization Record: Emergency Form: Proof of Mortgage Residency Statement Official Enrollment Date: Grade Student Is Entering:
Transportation Form: Birth Certificate:
Report Card: Other:
Utility Lease Bill Anticipated Date of Attendance:
Other
Signature of Charter School Representative: Page 2 of Charter School Student Enrollment Notification Form
PDE 2/2008
REQUEST FOR TRANSPORTATION UNDER ACT 372 (PLEASE COMPLETE A SEPARATE FORM FOR EACH CHILD NEEDING BUS TRANSPORTATION)
Date: _____________ Name of Child: _____________________________ Birth date ___/___/___ Grade: _____(2016-2017) Address: ________________________________________________________________ I do request transportation at this time: ______ I do not request transportation at this time: ______ If requesting bus transportation, please complete the following information: Bus Stop: (If known) _______________________________________________________ Name of School: Lehigh Valley Charter Academy Name of public school district in which child resides: __________________________________ If child received public school transportation last year, please indicate the bus number and district. Bus # ____________
District: ____________________________
Mother’s Information
Father’s Information
Name (Please Print)
____________________________
__________________________
Home Phone #
____________________________
__________________________
Work Phone #
____________________________
__________________________
Cell Phone #
____________________________
__________________________
Parent(s) Signature:
____________________________
__________________________
Emergency Contact Names & Phone #’s (other than parents): Name: _________________________________
Phone: _______________________
Name: _________________________________
Phone: _______________________
Administration Only
Home School District Approval: ________________________________________ Date: ________________________ Verify Miles from School: ___________ Address Verification: _____________ Date: __________________________
