Pre-Registration Form 2015-2016 Academy Adventures Midtown School 3025 N. Winstel, Tucson, AZ 85716 * Phone: (520) 777-3757 Admission is not based upon ethnicity, national origin, gender, income level, disabling condition, proficiency in the English language or athletic ability. WHERE DID YOU HEAR ABOUT US? Saw Signs Drove by Website Referred by: _________________ Other: ________ STUDENT INFORMATION Legal Last Name First Name Home Phone # Date of Birth Home Address Federal Ethnicity (Required): Hispanic or Latino Not Hispanic or Latino Asian Native Hawaiian or Other Pacific Islander American Indian/Alaskan Native (Tribe: ________________________________) Gender: Male Female Federal Race (Required): White City/State/Zip 2015-16 Grade Level: Black/African American What is the Primary Language of the child? (Please check ONE) English Spanish Other: ________________________ Student Lives With: Both Parents Mother Only Father Only Step Parent Legal Guardian Student & Family reside in: Permanent Residence Temporary Residence Shelter/Group Home Student is currently Homeless: Yes No Student or Family Requests Additional Information Regarding Available Services: Yes No PARENT/GUARDIAN INFORMATION Mother’s Name Address, if same as above check here, if not, fill in below Address Father’s Name Address, if same as above check here, if not, fill in below Address City/State/Zip City/State/Zip Home Phone # Home Cell # Cell # Work # Cell # Email: Work # Email: Student Lives With: Who Has Legal Custody: Parents Parents Mother Mother Father Father Other (specify and name) Other (specify and name) STATEMENT OF DISCLOSURE I/We have truthfully answered all questions on this enrollment form. I/We understand that student grade level placement is based upon previous grades/credits, recommendations, and test scores. I/We understand that any false information on the application will be grounds for expulsion from the school. I/We understand that this application does not guarantee enrollment, but is only the first step of the enrollment process. Parent/Guardian Signature(s): Name Signature Date Name Signature Date Please Note This Pre-Registration Form Does Not Complete Your Child’s Enrollment! The following must be on file at the school before the first day of school or your child will not be able to start. Completed Enrollment Packet* Completed Arizona Residency Form and Approved Documentation Birth Certificate Complete Immunization *If you have not received an enrollment packet by July 15, 2015, please contact the school. If you move during the summer please be sure to update your address and phone number so that we can update our records and ensure that you receive all information sent out during summer.
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