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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)

Street Address

City

State

Zip Code

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:


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:

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

Street Address

City

State

Zip Code

Mailing Address

City

State

Zip Code

Does Parent One live with student?
 Yes No

Home Phone

Cell Phone

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 Education



PARENT TWO:

Parent Two Name

Relationship to student

Street Address

City

State

Zip Code

Mailing Address

City

State

Zip Code

Does Parent Two live with student?
 Yes No

Home Phone

Cell Phone

Work Phone

Email Address

Employer

Is Parent Two Employer a Federal Employer?
 Yes No

Is Parent Two 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 Two?
 Yes No

Parent/ Guardian Two Highest Level of Education


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:

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:

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):

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)

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