Would you prefer email communication to replace mailing? Note email address below YES / NO

A-H Regional Night School 2016 - 2017

Wednesday Evening (5:30-7:00 & 7:00-8:30pm) 763-506-7407 (Phone) 763-506-7403 (Fax) Student ID: _________________________________ Student Name: _________________________________________________________________ Date of Birth: ______________________________ (Last)

(First)

(Middle)

Address: ______________________________________________________________________ Home Phone #: _____________________________ (Street)

(City)

(Zip code)

Parent/Guardian:_______________________________________________________________

Cell/Alt. Phone #: __________________________

Parent/Guardian contact email address: Name of Current/Last School Attended (Circle):

Original Grad Year: _______________________ Andover

Anoka

Subject English 9 English 10 English 11 English 12 Civics 9 Human Geog. 9 US History 10 World History 11 Gov’t & Politics 12 Economics 12 Electives (Apex)*

A

B

Coon Rapids

Other: _________________

*ELIGIBILITY CRITERIA – CREDIT

Subject Physical Science 9 Biology Chemistry Geometry Intermediate Algebra Stats & Prob Adv. Algebra Phy Ed I Phy Ed II Health Art (meets Art credit)

Champlin Park

(Specify name of School)

Please check A or B if applicable. CREDIT

Blaine

A

B

*i.e. Art Appreciation or Music Appreciation

Were any Partial Units earned for passing at mid-term? If so, indicate the partial unit amount earned (i.e. 30), subject and school

1. 2. 3. 4. 5. 6.

* Please circle criteria that applies to student Student is performing substantially below performance on local achievement tests. Student is at least one year behind in satisfactorily completing coursework. Student is or has been homeless sometime in the last 6 months. Student has a limited English proficiency or speaks English as a second language. Student has been chronically truant or has withdrawn from school. Student has been referred by a school district for enrollment in an eligible nontraditional program Student is pregnant or a parent. Student has been sexually or physically abused. Student has been excluded or expelled. Student has experienced mental health problems.

7. 8. 9. 10. 11. Other: __________________________________________________________ Counselor Signature: ______________________________________________ Parent Signature: _________________________________________________ Student Signature: ________________________________________________ Case Manager Signature: ___________________________________________ (No Special Ed Services are provided during the Night School Program)

Partial Units ______ Subject __________________ School __________________

Date: ____________________________________________________________

Partial Units ______ Subject __________________ School __________________

CLP (required for All Learner Year Referrals): _______ Student is required to attend and complete required credit during Credit Recovery Night School Program in the current school year. _______ Other: _______________________________________

Has student previously attended AHRHS Night or Summer School? YES / NO