For District Use Only

FOR DISTRICT USE ONLY

Interview Date: / / SAIS ID#:
Entry/Re-Entry Date: / Chicanos Por La Causa / School ID #:
Entry/ Re-Entry Code: / Community Schools / Date of Birth:
Withdrawal Date: / Items Submitted:
Withdrawal Code: /

School Year 2017-18

/ Immunization Records
Assessment Date: / Birth Certificate
Freshman Year: / Envision High School Toltecalli High School / Official Withdrawal Form
Cohort Class: Grade: / 3550 N. Oracle Rd. 251 W. Irvington Rd. / Official/Unofficial Transcripts
Last High Schools/District Attended: / Tucson, Az. 85705 Tucson, Az. 85713 / 8th Grade Certificate (if applicable)
Date data entered in School Master: /

Pre-Enrollment Enrollment Re-Enrollment

/ State Testing Results
Name of Person entering data: / IEP/MET Records

STUDENT PERSONAL DATA

Legal Last Name: / First: Middle: / Nickname:
Address: / City: State: / Zip:
Mailing Address: / City: State: / Zip:
Telephone: ( ) / Work Telephone: ( )

Sex: Female Male

Race: White African American Asian Native Hawaiian/ Pacific Islander American Indian / Alaskan Native Tribal Affiliation: ______

Are you Hispanic or Latino? Yes No

LANGUAGE SURVEY

What is the primary language used in the home regardless of the language spoken by the student? English Spanish Other: ______

What is the language most often spoken by the student? English Spanish Other: ______

What is the language that the student first acquired? English Spanish Other: ______

SPECIAL PROGRAMS

Has the student ever been enrolled in a Special Education Program? Yes No

Has the student ever been enrolled in a 504 Plan? Yes No

Has the student ever been enrolled in a Gifted Program? Yes No

Has the student ever been enrolled in an English Language Learner Program? Yes No

MIGRANT STATUS

Has your family moved in the last 3 years to seek farm work? Yes No

SCHOOL HISTORY

Have you been suspended within the last 12 months from another district? Yes No

Have you been expelled within the last 12 months from another district? Yes No

If yes to either of the two above, please state the reason:

PROBATION STATUS

Have you ever been convicted of a felony or a misdemeanor?
If yes, reason: /

Yes No

Is student on probation? Yes No / If yes, probation officer’s name:
Telephone #: /

Cell #:

/ Pager #:

PARENT/GUARDIAN INFORMATION

Parent/Guardian Name: / Telephone:
Mailing Address: / Cell Telephone:
Parent/Guardian Employer: / Email Address: / Bus. Telephone:

TRANSPORTATION INFORMATION

Do you have a low-income Sun Tran bus I.D.? Yes No

Please check the mode of transportation you plan to utilize.

Bus Own Vehicle Walking Parent will transport Bicycle Other ______

ADDITIONAL INFORMATION

How did you hear about our school? Please mark all that apply.

Friend Parents/Guardian Flyer/brochure Family Member Passing By School Sun Tran Other:______

AUTHORIZATION

We certify that the information provided is true and correct to the best of our knowledge. Our signatures acknowledge that we have been informed of the expectations of Chicanos Por La Causa Community Schools; a copy of the Student/Parent Handbook policies and procedures will be given to us during the parent/student orientation. We agree to read all of the contents of the Student/Parent Handbook. As a student of Chicanos Por La Causa Community Schools, I agree to abide by the school policies and procedures. Failure to do so may result in loss of my enrollment privileges.

Date: / Student Signature: / Date: / Parent Signature: