URSA Enrollment Application Form
Must be a Kansas resident to enroll. Each application will be reviewed prior to acceptance. Acceptance into URSA will be determined by the URSA directors and coordinator. 
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Email *
Student First Name:  *
Student Middle Initial: *
Student Last Name: *
Maiden Name or Other Names Used:
Enrollment Type *
Student Phone Number: *
Student Email *
Address: (Street, City, State, Zip) *
Date of Birth: (MM/DD/YYYY) *
Gender: *
Age: *
Ethnicity: *
Hispanic or Latino: *
Employed? *
Last Grade Completed? *
Former School: (Name, City, State) *

I give URSA permission to request, transfer or discuss my school records with other schools or post-secondary choices. 
Why are you interested in leaving your current schooling option? *
21 & Under: Do you currently have an IEP? *
Services provided under your current IEP? (Check all that apply)
List Three Additional Contacts: (Friends/ Family/Guardian, Name and Phone Number) *
I give consent to the URSA staff to discuss my progress or attendance with the person(s) listed above. Initials below:
Do you have a probation officer? *
Do you have a caseworker? *
Do you have a computer?
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Do you have internet service?
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By submitting this form, I am providing my digital signature agreeing that the information given on this form is true, complete and accurate. Please type inital:
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