EECS Registration Form
Sign in to Google to save your progress. Learn more
Student Legal Name (First, Middle, Last)

 *
Date of Birth *
MM
/
DD
/
YYYY
Student Phone Number (xxx) xxx.xxxx  (If applicable)
Is the Student Phone number a mobile phone?

If you did not provide a Student Phone Number above, please check "Does Not Apply".
Clear selection
Student Personal Email Address *
Student Primary Address (Street, City, State, Zip Code) *
Student Mailing Address

If the same as the Student Primary Address, please put "Same"
 *
Legal Guardian/Caregiver

First Name, Last Name, Relationship to Student

If you (the Student) are your Legal Guardian/Caregiver, please put "Self"
 *
Does the Legal Guardian/Caregiver have custody of the student?

If you marked "Self" above, check "Self" below.
 *
Is Legal Guardian/Caregiver the emergency contact?

If you marked "Self" above, check "Self" below.
 *
Does the the Legal Guardian/Caregiver live with the student?

If you marked "Self" above, check "Self" below.
 *
Can the Legal Guardian/Caregiver pick up the student?

If you marked "Self" above, check "Self" below.
 *
Legal Guardian/Caregiver Phone Number

(xxx) xxx.xxxx

If you marked "Self" above, put "Self" below.
 *
Is Legal Guardian/Caregiver phone number a mobile phone?

If you marked "Self" above, check "Self" below.
 *
Legal Guardian/Caregiver Email Address

If you marked "Self" above, put "Self" below.
Legal Guardian/Caregiver Address

Street, City, State, Zip Code

If you marked "Self" above, put "Self" below.
 *
Legal Guardian/Caregiver Mailing Address

Street, City, State, Zip Code

If you marked "Self" above, put "Self" below.
 *
Additional Contact 1

First Name, Last Name, Relationship to Student
Does Additional Contact 1 have custody of the student?
Clear selection
Is Additional Contact 1 the Emergency Contact? *
Does Additional Contact 1 live with the student?
Clear selection
Can Additional Contact 1 pick up the student?
Clear selection
Additional Contact 1 Phone Number

(xxx) xxx.xxxx
Is Additional Contact 1 phone number a mobile phone?
Additional Contact 1 Email Address
Additional Contact 1 Address

 Street, City, State, Zip Code
Additional Contact 1 Mailing Address

 Street, City, State, Zip Code
Additional Contact 2

First Name, Last Name, Relationship to Student
Does Additional Contact 2 have custody of the student?
Clear selection
Is Additional Contact 2 the Emergency Contact?
 *
Does Additional Contact 2 live with the student?
Clear selection
Can Additional Contact 2 pick up the student?
Clear selection
Additional Contact 2 Phone Number

(xxx) xxx.xxxx
Is Additional Contact 2 phone number a mobile phone?
Additional Contact 2 Email Address
Additional Contact 2 Address

 Street, City, State, Zip Code
Additional Contact 2 Mailing Address

 Street, City, State, Zip Code
Please list any siblings enrolled to attend EECS.

If none, then please put "None".
 *
This question is related to the Home Language Survey.

What is the student's country of birth? *
This question is related to the Home Language Survey.

What is the primary language spoken in the home? *
This question is related to the Home Language Survey.

What was the student's first language learned? *
What is your preferred language to receive information from the school?

(This includes any information send via the postal mail, email, text message, and voice recordings.)
 *
Student Ethnicity/Race *
Required
Gender *
Has this student attended school before? *
What was the name of the last school attended? *
What is the last grade completed? *
Did your student have an IEP at your last school/district?

IEP Description
An IEP, or Individualized Education Plant, is a legal plan for students who qualify for special education. 

IEPs are created by a team of parents, teachers, and specialists.  The IEP sets goals based on the student's strengths and needs.  It may include but is not limited to extra support, special instruction, or accommodations.
 *
Did your student have a 504 plan at your last school/district?

504 Plan Description
A 504 Plan is legal plan that supports students with a disability, and do not qualify for an IEP.

504 plans are created by a team of parents, teachers, and school staff.  The goal of the 504 plan is aid the student in having access to the general classroom instruction.
 *
Does your student have Behavior Intervention Plan? *
The following questions are intended to address the McKinney - Vento Act 42 U.S.C 22432 et seq.  The answers to this residency information help determine the services the student may be eligible to receive.

Question 1 - The student lives with:
 *
The following questions are intended to address the McKinney - Vento Act 42 U.S.C 22432 et seq.  The answers to this residency information help determine the services the student may be eligible to receive.

Question 2 - Which option applies to the student:
 *
If your family lives in any of the following, you may qualify for certain rights and protections under the federal McKinney - Vento Act: 

A Homeless Shelter
Doubled Up with other people
Car, park, empty building or bus
Motel or campground

I have read and understand my rights and protections under the federal McKinney - Vento Act.
 *
Family Physician Name
Family Physician Phone Number
Family Dentist Name
Family Dentist Phone Number
Do you have health insurance?
Clear selection
If the student has any allergies, please list them below.

If the student does not have any allergies, please put "NA"
 *
If the student has any documented medical conditions, please list them, and add any relevant description.

If the student does not have any documented medical conditions, please put "NA".
 *
If the student is taking any medications, please list then below.

If the student is not taking any medications, please put "NA"
 *
If the student is taking any medications, will they need to take them while at school? *
I have read and agree to the terms of the policy of the Code of Conduct.

Link to Code of Conduct is HERE.
 *
Acceptable Use Internet Policy

Empowering Excellence Charter School students must follow these guidelines when using the Internet for school-related work:

Respect the privacy of others by using only assigned accounts and not accessing passwords, data, or networks without authorization.

Protect the integrity, availability, and security of electronic resources by observing network security practices and reporting any violations.

Respect the intellectual property of others by avoiding copyright infringement and plagiarism.

Communicate in a kind and respectful manner and report any threatening or discomforting materials to school administration.

Refrain from accessing, transmitting, copying, or creating illegal or inappropriate material, including spam and chain letters.

I have read and agree to the terms of the policy.
 *
I have read and agree to the terms of the policy.

Link to Photo/Video Release is HERE
 *
Based on the guidelines linked below, do you believe your student qualifies for the Free and Reduced Lunch Program?

Free & Reduced Lunch Guidelines *
I agree for the student's records to be released from their previous school and shared with EECS. *
Student Preferred Method of Contact (Check All That Apply)
 *
Required
Legal Guardian/Caregiver  Preferred Method of Contact (Check All That Apply)
 *
Required
Additional Contact 1 Method of Contact (Check All That Apply)
Additional Contact 2 Preferred Method of Contact (Check All That Apply)
Will the student require a school computer?
 *
Will the student require a school hotspot?
Clear selection
Skip the Trip – Iowa Driver Permit Exam:
Students who are between the ages of 14 and 17 are eligible to participate in the IA Driver Permit Exam offered through the Skip the Trip program.

Please note that students who are 18 years of age or older are not eligible to participate in this program.  Register in the link below.   https://forms.gle/1m99B1nq4jiWAiXr7

 *
How did you hear about EECS? *
By checking "Yes" below, you are confirming your understanding this registration is for 2026-2027 school year *
I certify that the information provided is accurate and complete to the best of my knowledge.

Please write your name and the date below to signify your signature for this form.
 *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Empowering Excellence Charter School.

Does this form look suspicious? Report

Google Forms