Charlotte Choice Charter

Scholar Information:

Scholar Name: ______Promoted Grade:______

Scholar’s Mailing Address: ______

Telephone Number: ______Student Ethnicity: ______

Gender: qMale qFemale Scholar’s Date of Birth: ______

Name of Last School Attended: ______

Name of Last School District: ______

Last Completed Grade Level: ______Scholar’s Spoken Language: ______

Parent/Guardian Information

Mother/Guardian
Name ______
Address ______
______
Home # ______
Work # ______
Cell # ______
E-mail Address: ______/ Father/Guardian
Name ______
Address ______
______
Home # ______
Work # ______
Cell # ______
E-mail Address: ______

Exceptional Children Information

Does the scholar have a disability? qYes qNo

If yes, what is the disability? ______

Does the scholar have an IEP? qYes qNo

Does the scholar have AIG/TD certification? qYes qNo

Does the scholar have a 504 Plan? qYes qNo

Medical Information

Physician: ______Telephone Number: ______

Hospital Preference: ______

Chronic Illness/Injury: ______

Allergies (including medications): ______

Are there any physical limitations? qYes qNo

If yes, what are they? ______

What medications does the scholar take? ______

Transportation:

All scholars of the Charlotte Choice Charter who live within the school’s transportation are eligible for transportation services via our cluster stop system.Please answer the following question below in order for your child’s transportation needs to be assessed.

Will your child need transportation for the upcoming 2017-2018 school year? ______

Home Language Survey Scholar Information

First Name: / Last Name:
Country of Birth: / Date first enrolled in any U.S. school (Private or Public, but not Pre-K). Indicate if the scholar left the U.S. for a school year(s): / Date of Birth:
Current School: / School Enrollment Date: / Current Grade:
Questions for Parents/Guardians / Parent Response
What is the first language the scholar learned to speak?
What language does the scholar speak most often?
What language is most often spoken in the home?

*****************************For Office Use Only***************************

Person Reviewing this Survey: ______

Determination
The scholar’s home language / Language:
If the language is other than English, the English language proficiency test should be administered / Administer the English Language Proficiency Test
Circle: Yes or No

Charlotte Choice Charter School

3118-A Milton Rd Charlotte, NC 28215

Phone 980-272-8308

PERMISSION TO RELEASE SCHOOL RECORDS

Under the provision of section 99.30 of the Family Educational Rights and Privacy Act, this signed document authorizes the release of all school and health records for the student listed below.This school listed below (Previous School) has been named as the last school the student attended.The student’s records will be kept on file atCharlotte Choice Charter School.These Records will be subject to the confidentiality rules of the State of North Carolina.Only authorized personnel will have access to this student’s record. The student’s prior school, as listed below, is required by the above provision to disclose all student’s records, including but not limited to any Individualized Education Plan, Immunization Records, and medical history kept on record with student’s records within 14 days from receipt of this from receipt of this form to the above address.

Student Name:______DOB: ______Current grade: ______

Name of school currently attending: ______School’s address: ______School’s phone number: ______Parent signature: ______