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
Your answer
Gender
FORMAT: M or F
Your answer
Current/Rising Grade
FORMAT: First Grade, Rising Second Grade
Your answer
Race (optional)
Your answer
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?
Your answer
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:
Your answer
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:
Your answer
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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