Aspire Charter Academy

A Positive Behavior Support School

Application
GRADES K-2

2011- 2012 School Year

www.aspirecharteracademy.com
To be filled out by ACA office staff only:

OCPS STUDENT ASSIGNED

NUMBER:___________________________________

Last Name, First Name of Student:

________________________________________________________

I. PART ONE:

DATE OF APPLICATION:

(TODAYS DATE): _________

Student Name _____________________________ DOB: __________ Last Grade attended: __________

( last name, first name )

Previous School _____________________________ City: ______________ State ______

Last Date attended Previous School: _____________________

Did you complete the grade requirements? _________________________

Do you have a withdrawal form from past school? ________Yes ______No______ Date:___________

Please indicate if your child currently has an IEP. _________Yes _________No

Primary Guardian: Student lives with ____both parents; ___ one parent: ___shared custody; ___Other

Guardian’s Name
___________________________________________________________________________________

First Last M.I.

Mother Father Grandparent Legal Guardian OtherAddress

Relationship to Student:
______________________________________________________________________________
Number Street Apartment #
___________________________________________________________________________________
City State Zip Code

Work Phone _______________ Home Phone ________________ Cell Phone________________

Guardians’ E-Mail Address: ______________________ Student’s E-Mail Address:___________________

II. PART TWO:

EMERGENCY CONTACT INFORMATION:

CONTACT ONE: Does this person have permission to pick up/dismiss your child? Yes or No
(circle one)
Name: ______________________________________ Relationship to Parent: _______________
(last name, first name)
Address ______________________________________________________________________________
Number Street Apartment #
___________________________________________________________________________________
City State Zip Code

Work Phone _______________ Home Phone ________________ Cell Phone________________

CONTACT TWO: Does this person have permission to pick up/dismiss your child? Yes or No
(circle one)

Name: ______________________________________ Relationship to Parent: _______________

(last name, first name)
Address ______________________________________________________________________________
Number Street Apartment #
___________________________________________________________________________________
City State Zip Code

Work Phone _______________ Home Phone ________________ Cell Phone________________

If you have any questions or concerns, please contact the Aspire Charter Office
AspireSFox@gmail.com

PART III: RELEASE OF RECORDS INFORMATION

Aspire Charter Academy, Orange County, Florida

By signing this application, I hereby authorize Aspire Charter Academy (ACA) to receive all
available academic and medical records concerning my child. I understand that it is ultimately my
responsibility to request these records and have them forwarded to the ACA; however, ACA may
request school records, medical records, and obtain character references from any and all available
sources in order to gain a full understanding of the character of my child.
Parent/Guardians Signature:

_____________________________________Date:__________________________
PART IV: FAMILY MEMBERS IN ORANGE COUNTY SCHOOLS:

SIBLINGS: List the names, date of birth and schools attended :

Sibling Name: DOB School Attending

PART V: How will your child get to school?

__ walk __ parents __ city bus __ guardian ___ need transportation (between 2-4 miles only)

PART VII: Are you interested in applying for Free or Reduced Lunch Status?

__ You were eligible at last school. ___You do not know if you qualify. __Help me understand.

PART VIII:

What other special circumstances do we need to know in order to assist your child?