2019-2020 Enrollment Form
Email address *
How did you hear about Byron Center Charter School, if referred, who referred you?
Your answer
Student's Name: (Last, First) *
Your answer
Date Of Birth *
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DD
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YYYY
Home Phone Number *
Your answer
Grade Entering: *
Your answer
Student's Street Address: *
Your answer
City and State *
Your answer
Zip Code *
Your answer
Ethnicity (select all that apply) *
Father's Name (Last, First) *
Your answer
Father's Day Phone or Cell Phone *
Your answer
Father's Employer *
Your answer
Father's Home Phone *
Your answer
Student's Gender *
Guardianship (Student resides with, check all that apply) *
Guardian Email Address (for school news, etc) *
Your answer
Mother's Name (Last, First) *
Your answer
Mother's Day Phone or Cell Phone *
Your answer
Mother's Employer *
Your answer
Mother's Home Phone Number *
Your answer
Student's Language *
Home Language *
Enrollment history (for new student's only): Does your child receive any of the following services? *
Required
Is your student currently expelled, suspended, or recommended for expulsion or long-term suspension? *
School Previously Attended *
Your answer
Emergency Contact Name 1 *
Your answer
Emergency Contact Phone Number (specify home or cell) *
Your answer
Emergency Contact Name 2 *
Your answer
Emergency Contact Phone Number (specify home or cell) *
Your answer
Medical Information: Please tell us if your student has any medical conditions, allergies or takes any medication that you feel we should be aware of: *
Your answer
I hereby give permission for my student to be transported in a vehicle and participate in field trips. I understand that field trips are a part of the school's educational program and provides a learning experience of educational value to my student. *
I hereby give permission to Byron Center Charter School to secure emergency medical treatment for the above named student while in their care. Release and agree to hold the Board of Education, It's officials and it's staff harmless from any and all liability for damaged or injury resulting directly or indirectly for this authorization, I understand that the school staff is not medically trained. *
I affirm, that as the parent/legal guardian, all information provided above is true and accurate, and that my student and I reside at the listed address. I understand any false information provided by me, may subject me to legal penalties for perjury. *
Byron Center Charter School is authorized to use our son/daughter's photo/video in school publications/advertisements to promote events and or enrollment in local media, unless a written objection is filed with the office within 3o days of enrollment. *
A copy of your responses will be emailed to the address you provided.
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