Student Enrollment Form – College Achieve Public Charter School

Scholar's Name:

Student's First Name (as on birth certificate) *

Student's Middle Initial

Student's Last Name (as on birth certificate) *

Scholar's Address:

Street Address *

City *

State *

Zip Code / Postal Code *

Personal Information:

Sex *

Birth Date *

City of Birth *

Country of Birth * Country of Birth

State of Birth * State of Birth

Parent's/Guardian's Information:

Parent/Guardian - First Name *

Parent/Guardian - Last Name *

Relation to Student * Relation to Student

2nd Parent/Guardian - First Name

2nd Parent/Guardian - Last Name

Relation to Student Relation to Student

Cell Phone NOTE: You need AT LEAST ONE phone number. *

Home Phone *

Work Phone

Email 1 *

Email 2

Grade as of Sept. 2021 *

Current Grade *

Current School (Name) *

Current School (City, State) *

Assigned District Public School *

Do you currently have a child attending College Achieve Asbury? *

Yes

No

If yes, what is your child's first name?

If yes, what is your child's last name?

If yes, what grade is your child in?

Is your student of Hispanic/Latino orgin? *

Yes

No

I choose not to provide the above data for my student. I understand that College Achieve Asbury and the State of New Jersey are required to provide this information to the federal government. I understand that College Achieve Asbury Charter School will be required to select race and ethnicity categories on my behalf.

Race *

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or other Pacific Islander

I choose not to provide the above data for my student. I understand that College Achieve Asbury Charter School and the State of New Jersey are required to provide this information to the federal government. I understand that College Achieve Asbury will be required to select race and ethnicity categories on my behalf.

Do you have health insurance? *

Yes

No

Is your child’s native tongue a language other than English? *

Yes

No

If yes, what is the language?

Is the primary language used in your child’s home a language other than English? *

Yes

No

If yes, what is the language?

Emergency Contact Information:

First Name *

Last Name *

Email 1 *

Email 2

Mobile Phone NOTE: You need AT LEAST ONE phone number. *

Home Phone

Work Phone

The electronic signature below, and all of its related fields, replace a handwritten signature on paper and is legally binding. 
"I verify the above information to be correct, and I understand that completion of this form does not guarantee placement in a school. I further understand that I cannot register my child without appropriate address documentation and that only one application can be submitted per child. I further understand that it is my responsibility as the Parent/Legal Guardian to immediately inform the school of any changes to the information provided."

I Agree *

I Agree

Electronic Signature *

Date *

Registration Form 2024-2025

Scholar's Name:

Scholar's Address:

Personal Information:

Parent's/Guardian's Information:

Emergency Contact Information: