Student Enrollment Form – College Achieve Public Charter School

Student's First Name (as on birth certificate) / Nombre del Estudiante (como en su Certificado de Nacimiento) *

Student's Middle Initial

Student's Last Name (as on birth certificate) / Apellido del Estudiante (como en su Certificado de Nacimiento) *

Street Address *

City *

State *

Zip Code / Postal Code *

Sex / Sexo *

Birth Date (must be 10/1/2016 or earlier) / Fecha de Nacimiento (debe ser 10/1/2016 o anterior) *

Country of Birth * Country of Birth

State of Birth * State of Birth

City of Birth / Ciudad de Nacimiento *

Parent/Guardian - First Name (Padre / Tutor - Nombre) *

Parent/Guardian - Last Name (Padre / Tutor - Apellido) *

Relation to Student * Relation to Student

2nd Parent/Guardian - First Name (Padre / Tutor - Nombre)

2nd Parent/Guardian - Last Name (Padre / Tutor - Apellido)

Realtion to Student Realtion to Student

Cell Phone / Tel - Celular NOTE: You need AT LEAST ONE phone number. Necesita AL MENOS UN número de teléfono. *

Home Phone / Tel - Casa *

Work Phone / Tel - Trabajo

Email 1 *

Email 2

Grade as of Sept. 2021 / Grado escolar para Sept. 2021 *

Current Grade *

Current School (Name) / Escuela Que Asiste Actualmente (nombre) *

Current School (City, State) / Escuela Que Asiste Actualmente (Ciudad, Estado) *

Assigned District Public School / Distrito de Escuela Actual *

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?

First Name *

Last Name *

Email 1 *

Email 2

Mobile Phone NOTE: You need AT LEAST ONE phone number. Necesita AL MENOS UN número de teléfono. *

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."

La firma electrónica abajo y todos sus campos relacionados, reemplaza una firma manuscrita en papel y es legalmente válida. 
"Verifico que la información anterior es correcta y entiendo que la terminación de este formulario no garantiza la colocación en una escuela. Además, entiendo que no puedo inscribir a mi hijo sin la documentación de la dirección apropiada y que sólo se puede enviar una solicitud por niño. Además, entiendo que es mi responsabilidad como el Padre / Tutor Legal informar inmediatamente a la escuela de cualquier cambio en la información proporcionada."

I agree / Estoy de acuerdo *

I Agree

Electronic Signature / Firma Electrónica *

Date *

Registration Form 2022-2023 / Forma de Matriculación 2022-2023

Summer In Person Registration Hours 9:00-2:00