URSA Enrollment Application Form

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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.

Email *

Student First Name: *

Student Middle Initial: *

Student Last Name: *

Maiden Name or Other Names Used:

Enrollment Type *

New Student

Returning Student

Student Phone Number: *

Student Email *

Address: (Street, City, State, Zip) *

Date of Birth: (MM/DD/YYYY) *

Gender: *

Male

Female

Age: *

Ethnicity: *

White

African

Asian

Indian

Pacific

Other:

Hispanic or Latino: *

Yes

Employed? *

Yes

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.
*

Yes

Why are you interested in leaving your current schooling option? *

21 & Under: Do you currently have an IEP? *

Yes

Services provided under your current IEP? (Check all that apply)

Resource Room

Extra Time on Tests

Reading

Math

Behavior

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? *

Yes

Do you have a caseworker? *

Yes

Do you have a computer?

Yes

Clear selection

Do you have internet service?

Yes

Clear selection

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:
*

I agree.

Send me a copy of my responses.

Submit

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