ACADEMIC YEAR 17-18 ENROLLMENT APPLICATION
HAVE QUESTIONS? NEED MORE INFORMATION? EMAIL US TODAY: INFO@NCFC-DC.ORG
Select check the program in which you are interested in *
STUDENT INFORMATION
Student first name *
Your answer
Student last name *
Your answer
Date of Birth *
FORMAT: 01/11/11
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Gender *
FORMAT: M or F
Your answer
Current/Rising Grade *
FORMAT: First Grade, Rising Second Grade
Your answer
Race (optional)
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Parent/Guardian Name *
Your answer
Relationship to child *
Language(s) spoken at home *
Your answer
How many children are in the home? *
Your answer
How many adults are in the home? *
Your answer
Which ward do you reside in? *
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Single Parent/Guardian household? *
Required
Full Mailing Address *
Your answer
Is this the child's primary residence *
Required
Home Phone *
FORMAT: 000.000.0000
Your answer
Work Phone *
FORMAT: 000.000.0000
Your answer
Cell Phone *
FORMAT: 000.000.0000
Your answer
Email address *
Your answer
EMERGENCY CONTACT INFORMATION
REQUIRED
EMERGENCY CONTACT #1 FULL NAME *
Your answer
RELATION TO CHILD *
EMERGENCY CONTACT #1
Your answer
PHONE NUMBER *
EMERGENCY CONTACT #1
Your answer
EMERGENCY CONTACT #2 FULL NAME *
Your answer
RELATION TO CHILD *
EMERGENCY CONTACT #2
Your answer
PHONE NUMBER *
EMERGENCY CONTACT #2
Your answer
KNOWN ALLERGIES *
Your answer
OTHER MEDICAL CONDITIONS *
Your answer
HEALTH INSURANCE PROVIDER *
Your answer
IDENTIFICATON # *
Your answer
SCHOOL INFORMATION
School currently attending *
Your answer
What academic area(s)/subject(s) does your child need support with? *
Your answer
Does your child have an IEP? *
If YES, what year did she or he begin with the IEP?
Your answer
Please indicate disability and services provided under IEP:
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Does your child receive free or reduced lunch? *
Has your child ever* been retained? *
If YES, in what grade(s)?
Your answer
Has your child ever* been retained? *
Are there any activities your child is not allowed to participate in due to physical restrictions? *
If your child has physical restrictions, please elaborate below:
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Can your child swim? *
Is there anything else you feel we should know about your child? *
Your answer
STUDENT EDUCATION RECORD RELEASE
Do you authorize NCFC and its staff to access your child's educational records from their current and/or previous school? Additionally, NCFC may conduct educational and developmental assessments of your child for placement and advocacy purposes. *
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