ENROLL ONLINE NOW:
The Parent/ Legal Guardian must submit the following documentation to Bayshore Preparatory Charter School (BPCS) to be considered for Enrollment: (please note: if you would prefer to fax: (760)736-0275, email: bspencer@bayshoreprep.org, or physically bring in these documents, please send at same time as Enrollment Application Form, as we cannot process your enrollment without these 6 items). Enrollment will be complete when you have received an appointment time with an Educational Consultant and the Master Agreement is signed and completed.
1.) Completed Enrollment Application Form Below
2.) One Form of Residency Verification (utility bill with parent or guardian's name shown at same address as student:
3.) Copy of Student Birth Certificate (Other Acceptable "Proof of Existence" that can be used: copy of student's Social Security Card, copy of student's Insurance Card, copy of student's Baby Dedication Card, copy of student's Baptism Certificate, OR a parent signed statement that his/her child was born on the given date):
4.) Copy of California School Immunization Record (Yellow Card if you have it - Other Ways Acceptable "Proof of Immunization" can be obtained: Doctor's office or clinic where shots were given most recently - if shots were given in more than one clinic this may take several phone calls, the California Immunization Registry www.ca-siis.org, OR a copy from a previous school)
5.) Unofficial/ Official Transcript/ Report Card from previous school with checkout grades:
6.) Proof of Withdrawal from Previous School:
ENROLLMENT APPLICATION FORM:
STUDENT INFORMATION:
First Name
Middle Name
Last Name
Suffix
Alias First Name
Alias Middle Name
Alias Last Name
Alias Suffix
Gender Male Female
Grade Level K 1 2 3 4 5 6 7 8 9 10 11 12
If your child is in Kindergarten or 1st Grade please upload your Health Check Form Here:
Birth Date (mm/dd/yyyy)
Birth City
Birth State/ Province
Birth Country
PHYSICAL ADDRESS:
Street Address
City
State
Zip Code
Is the Physical Address permanent housing? Yes No
If the Physical Address does NOT represent Permanent Housing, please briefly describe what type of Temporary Housing the physical address represents.
MAILING ADDRESS: (if different from street address)
Is student a foreign student temporarily schooling in the U.S.? Yes No
Was student born outside the U.S. but granted U.S. citizenship at birth? Yes No
Has student been enrolled in U.S. schools LESS that 3 cumulative years? Yes No
Home Phone
Cell Phone
Student Email Address
County of Residence
School District of Geographic Residence
ETHNICITY: (New federal race and ethnicity data collection/reporting requirements begining in 2009-2010 require all students to identify their ethnicity from the two choices) Is the Student Hispanic or Latino? No, not Hispanic or Latino Yes, Hispanic or Latino
RACE: (No matter what ethnicity is selected above, at least one race must be selected below) Choose one option: American Indian or Alaskan Native Hispanic/ Latino White Asian Indian Hmong Laotian Cambodian Japanese Vietnamese Chinese Korean Filipino Other Asian Other
PREVIOUS SCHOOL & ENROLLMENT DETAILS:
Name of Previous School
Address of Previous School
Is this an Interdistrict Transfer Student? No Yes (Formal Interdistrict Transfer) Yes (Transfer Involving Program Improve School) Yes (Transfer from Persistently Dangerous School)
Previous School Type:Public (in same district)Public (in a different district same state)Public (in a different state)Public (Charter school)Public (matriculated from another school/ completed highest grade level offered there)Private, NON-Religiously affiliated (in same district)Private, NON-Religiously affiliated (in different district, same state)Private, NON-Religiously affiliated (in a different state)Private, NON-Religiously affiliated (Home Schooling Family)Private, Religiously affiliated (in the same district)Private, Religiously affiliated (in a different district, same state)Private, Religiously affiliated (in a different state)Other (School outside of U.S.)Other (Institution, ex. correctional facility)
DATE first enrolled in the U.S. (mm/dd/yyyy)
DATE first enrolled in California (mm/dd/yyyy)
DATE first enrolled in Previous District (mm/dd/yyyy)
DATE first enrolled in Previous School (mm/dd/yyyy)
GRADE first enrolled in Previous District K 1 2 3 4 5 6 7 8 9 10 11 12
GRADE first enrolled in School (K-12) K 1 2 3 4 5 6 7 8 9 10 11 12
PARENT/ GUARDIAN INFORMATION: PARENT ONE:
Parent One Name
Relationship to student
Mailing Address
Does Parent One live with student? Yes No
Work Phone
Email Address
Employer
Is Parent One Employer a Federal Employer? Yes No
Is Parent One Military Active Duty? Yes No
If YES, please provide Branch
If YES, please provide Duty Station or Work Location
If YES, please provide Phone
Should Student Mailings be sent to Parent One? Yes No
Parent/ Guardian One Highest Level of EducationGraduate Degree - Holds MA, MS, PhD, or EdDFirst Professional Degree - Hold D.C., D.D.S., J.D., M.D., or OrdinationCollege Graduate - Holds BA or BSSome College - Holds AA or has completed 2 full years at a 4-year universityVocational CertificateHigh School Graduate - Holds diploma or GEDNot a High School GraduateDecline to State
PARENT TWO:
Parent Two Name
Does Parent Two live with student? Yes No
Is Parent Two Employer a Federal Employer? Yes No
Is Parent Two Military Active Duty? Yes No
Should Student Mailings be sent to Parent Two? Yes No
Parent/ Guardian Two Highest Level of EducationGraduate Degree - Holds MA, MS, PhD, or EdDFirst Professional Degree - Hold D.C., D.D.S., J.D., M.D., or OrdinationCollege Graduate - Holds BA or BSSome College - Holds AA or has completed 2 full years at a 4-year universityVocational CertificateHigh School Graduate - Holds diploma or GEDNot a High School GraduateDecline to State
HOME LANGUAGE SURVEY:
What Language did your child first learn to speak?
Which language does your child most frequently read/speak at home?
Which language do the parents/ guardians most frequently speak to the student?
Which language is most often spoken by the adults in the home?
Is your child fluent in English? Yes No
Has your child ever been in an EL Program? Yes No
Is your child currently still in an EL Program? Yes No
Date child exited EL Program (mm/dd/yyyy)
ESTIMATED ANNUAL HOUSEHOLD INCOME:
(This data will be used to ensure we have the resources available to best serve your students. It is strictly for informational purposes only. All information is confidential and will not be shared with any specific person or agency.)
Please Choose one of the options listed for family size and income range:Family Size: 1, Income: $0 to $10,830Family Size: 1, Income: $10,831 to $14,079Family Size: 1, Income: $14,080 to $20,036Family Size: 1, Income: $20,037+Family Size: 2, Income: $0 to $14,570Family Size: 2, Income: $14,571 to $18,941Family Size: 2, Income: $18,942 to $26,955Family Size: 2, Income: $26,956+Family Size: 3, Income: $0 to $18,310Family Size: 3, Income: $18,311 to $23,803Family Size: 3, Income: $23,804 to $33,874Family Size: 3, Income: $33,875+Family Size: 4, Income: $0 to $22,050Family Size: 4, Income: $22,051 to $28,665Family Size: 4, Income: $28,666 to $40,793Family Size: 4, Income: $40,794+Family Size: 5, Income: $0 to $25,790Family Size: 5, Income: $25,791 to $33,527Family Size: 5, Income: $33,528 to $47,712Family Size: 5, Income: $47,713+Family Size: 6, Income: $0 to $29,530Family Size: 6, Income: $29,531 to $38,389Family Size: 6, Income: $38,390 to $54,631Family Size: 6, Income: $54,632+Family Size: 7, Income: $0 to $33,270Family Size: 7, Income: $33,271 to $43,251Family Size: 7, Income: $43,252 to $61,550Family Size: 7, Income: $61,551+Family Size: 8, Income: $0 to $37,010Family Size: 8, Income: $37,011 to $48,113Family Size: 8, Income: $48,114 to $68,469Family Size: 8, Income: $68,470+
Should the field chosen above indicate that the student is eligible/ qualified for the National School Lunch Program, would you like to participate? Yes No
Is Parent/ Guardian employed in agricultural or fishing activities on a seasonal or other temporary basis? Yes No
PARENT/ GUARDIAN RELEASE SURVEY:
Parent grants his/her student permission to SIGN himself/herself in and out of the school: Yes No
Parent agrees to the High School "Open Campus" Policy: "YES" grants student permission to leave campus: Yes No
Student is allowed to use computers at school: Yes No
Student is allowed to access the Internet at school: Yes No
Parent gives permission to include student information in the school directory: Yes No
Parent grants permission to use pictures/video/audio of this student for school purposes: Yes No
Parent grants permission to use student work produced by this student for school purposes: Yes No
EMERGENCY CARD INFORMATION:
Person(s) Authorized to pickup student from School
Custody Issues Regarding Student:
Legal Restrictions for any parent:
EMERGENCY CONTACTS:
Contact One Name
Contact One Relationship to Student
Contact One Phone Number 1
Contact One Phone Number 2
Contact Two Name
Contact Two Relationship to Student
Contact Two Phone Number 1
Contact Two Phone Number 2
OTHER CHILDREN IN FAMILY:
Other child 1 Name
Other child 1 Relationship to Student
Other child 1 Gender Male Female
Other child 1 Date of Birth (mm/dd/yyyy)
Other child 1 School Currently Attending
Is Other child 1 over 18? Yes No
Other child 2 Name
Other child 2 Relationship to Student
Other child 2 Gender Male Female
Other child 2 Date of Birth (mm/dd/yyyy)
Other child 2 School Currently Attending
Is Other child 2 over 18? Yes No
Other child 3 Name
Other child 3 Relationship to Student
Other child 3 Gender Male Female
Other child 3 Date of Birth (mm/dd/yyyy)
Other child 3 School Currently Attending
Is Other child 3 over 18? Yes No
Other child 4 Name
Other child 4 Relationship to Student
Other child 4 Gender Male Female
Other child 4 Date of Birth (mm/dd/yyyy)
Other child 4 School Currently Attending
Is Other child 4 over 18? Yes No
HEALTH INFORMATION:
Medications Taken by Student at Home (written authorization from doctor required for school to administer):
Known Conditions (check all that apply): Asthma Bee Sting Allergy Diabetes Epilepsy Heart Condition Seizures Known Hearing Problem Preferential Seating Wears Hearing Aid Glasses to be Worn at All Times Known Eye Condition/ Defect in Vision Wears Contact Lenses Wears Glasses Other (Please Specify Below)
Other Health Conditions:
What action is to be taken is student has a complication due to his/her allergic condition (Please be Specific):
Health Insurance Carrier:
Insurance ID or Policy Number:
Hospital Preference:
Name of Physician:
Physician Address
Physician Phone Number
Name of Vision Doctor:
Name of Hearing Doctor:
ADDITIONAL REQUIREMENTS:
Has your child ever received any Special Education services of any kind? Yes No
If YES, Please provide a copy of Current IEP, including an exit IEP
By Checking the Box to the right and Providing my name below, I understand that I must Submit all Special Education Documentation, and/or 504 Plan with my child's enrollment paperwork, and that without it, my child cannot be enrolled with this Charter School. I certify that all statements are true and correct to the best of my knowledge. X
Has your child ever had disciplinary records/ suspensions/ expulsions of any kind? Yes No
If YES, Please provide a copy of the disciplinary records, including an exit notice.
By Checking the Box to the right and Providing my name below, I understand that I must Submit all disciplinary records/suspension/expulsion documentation, and that these documents will be reviewed by the school's executive director, with my child's Enrollment paperwork, and that without it my child cannot be enrolled in this Charter School. The Executive Director will make a final decision on enrollment and may require an interview during the decision process. I certify that all statements are true and correct to the best of my knowledge. X
If you have any other comments that you feel are important to share regarding your child's academic/school history that you think we should know, please write here:
How did you hear about Bayshore? (check all that apply) Referrel Internet Great School's Website Drove by Advertisement Other
ELECTRONIC SIGNATURE:
By Checking the Box to the right and Providing my name below, I certify that all of the statements and information given above are true and correct to the best of my knowledge and that if any information submitted on this document (or supplemental documents) is found to be false, this constitutes grounds for removal of my child from Bayshore Preparatory Charter School immediately. X
Submit Enrollment Form
