STUDENT INFORMATION
*Student First Name:
*Student Middle Name:
*Student Last Name:
*Student's Date of Birth:
=Select Month=
January
February
March
April
May
June
July
August
September
October
November
December
=Select Day=
1
2
3
4
5
6
7
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9
10
11
12
13
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19
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31
=Select Year=
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
Address:
Apt. #:
City
:
State:
Zip Code:
County of Residence:
Phone:
School District of Residence:
School Attended 2010-11 School Year
:
City of Prior School:
Student's Gender
:
Male
Female
Student's Ethnictiy: Is the student Hispanic/Latino?
Yes
No
Student's Race:
Alaskan Native or Native American
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
*Current Grade Level
This is the ____ time the student has ever entered this grade level.
First Time
Second Time
Third Time
PARENT/GUARDIAN INFORMATION
Who is the legal guardian of this student?
Guardian 1
First Name:
Middle Name:
Last Name:
Address
:
Apt. #:
City:
State:
Zip Code:
Home Phone:
Work Phone:
Cell Phone:
E-mail Address:
Relationship to Student:
Guardian 2
First Name:
Middle Name:
Last Name:
Address:
Apt. #:
City:
State:
Zip Code:
Home Phone:
Work Phone:
Cell Phone:
E-mail Address:
Relationship to Student:
DOES THE STUDENT HAVE ANY SIBLINGS?
Sibling 1
Name:
Sibling 1 Age:
Sibling 1 Current School:
Sibling 2
Name:
Age:
Current School:
Sibling 3
Name:
Age:
Current School:
Sibling 4
Name:
Age:
Current School:
EMERGENCY CONTACT INFORMATION
(other than parent/guardian)
Primary Contact
First Name:
Last Name:
Address:
Apt. #:
City:
State:
Zip Code:
Emergency Number
:
This is the
:
Cell
Work
Home
Relationship to Student:
This individual has permission to transport my child in the event of an emergency:
Yes
No
Secondary Contact
First Name:
Last Name:
Address:
Apt. #
:
City:
State:
Zip Code
Emergency Number
:
This is the:
Cell
Work
Home
Relationship to Student:
This individual has permission to transport my child in the event of an emergency:
Yes
No
FAMILY & STUDENT INFORMATION
English Proficiency of the student:
Native English Speaker
Fluent English Speaker
Non-English Speaking
Redesignated as Fluent English Proficient
Limited English Proficient/English Language Learner
Status Unknown
Primary Language Spoken at Home:
Arabic
Cantonese
Chinese (non Cantonese)
English
French
French Creole
German
Greek
Hindi
Italian
Japanese
Korean
Persian
Polish
Portuguese
Russian
Spanish
Tagalog
Urdu
Vietnamese
The School previously attended:
Public, in state
Public, out of state
Private, in state
Private, out of state
Original Entry into US school
Located outside of the country
Charter school
Home schooling
Has the student been determined as Gifted:
Yes
No
Has the student been classified by Special Education Services with any of the following disabilities:
Autistic/Autism
Hearing impairment
Multiple disabilities
Emotional disturbance
Speech or language impairment
Visual impairment (e.g. blindness, etc...)
Deafness
Mild/Moderate/Severe Disability
Attention Deficit Disorder
Deaf-blindness
Mental retardation
Orthopedic impairment
Specific learning disability
Traumatic brain injury
Other health impairment
Developmental delay
Other
None
Does the student currently have an IEP:
Yes
No
2011-2012 Grade Level
*
How did you hear about us?
Radio
TV
Newspaper
Friend/Relative
Current Student
Drove by School
Informational Event
Other (please specify below)
Use CTRL to select more than one.
Other
Fall Creek Academy | 2540 N. Capitol Avenue | Indianapolis, IN 46208
Phone: 317-536-1026 | Fax: 317-921-9453 |
FCAnfo@fallcreekacademy.org
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