The Academy of Tucson	ES	MS	HS
ES:	9209 E Wrightstown Rd, Tucson AZ 85715	PHONE: (520) 886-6076	FAX: (520) 886-6575	
MS:  7310 E 22nd St, Tucson, AZ 85710	PHONE: (520) 749-1413	FAX: (520) 749-2824	
HS:	10720 E 22nd St, Tucson, AZ 85748	PHONE: (520) 733-0096	FAX: (520) 733-0097	

SCHOOL YEAR: 20	- 20		ENROLLMENT FORM	GRADE ENROLLING IN: 		
STUDENT INFORMATION	
STUDENT LEGAL NAME:	GENDER:	F	M	DOB: 	
LAST	FIRST	MIDDLE

PHYSICAL ADDRESS: 	
STREET ADDRESS	CITY	STATE	ZIP CODE

MAILING ADDRESS: 	
(if different)	STREET ADDRESS	CITY	STATE	ZIP CODE

PREFERRED NAME:	 CITY OF BIRTH:	BIRTH STATE: 		

RACE:	White	American Indian/Alaska Native Black/African American	Asian/Pacific Islander

Is your child Hispanic/Latino?	Y	N

STUDENT LIVING WITH:	Both parents	Guardian

Mother ONLY	Father ONLY

Grandparent

(CHECK all that apply)	Mother/Stepfather	Father/Stepmother
Other (please specify): 	

CELL #: 		WORK #: 	
WORK

Number to use for contact:	HOME	CELL

LEGAL NAME:	RELATIONSHIP TO STUDENT: 	
LAST	FIRST
EMAIL ADDRESS:	OCCUPATION: 	
HOME #: 	

CELL #: 		WORK #: 	
WORK

Number to use for contact:	HOME	CELL

LEGAL NAME:	RELATIONSHIP TO STUDENT: 	
LAST	FIRST
EMAIL ADDRESS:	OCCUPATION: 	
HOME #: 	

PARENTS/GUARDIANS LIVING IN SAME HOUSEHOLD AS STUDENT

PARENTS/GUARDIANS LIVING AT AN ADDRESS DIFFERENT FROM STUDENT	
LEGAL NAME:	RELATIONSHIP TO STUDENT: 		
LAST	FIRST	
PHYSICAL ADDRESS: 		
STREET ADDRESS	CITY	STATE	ZIP CODE	
EMAIL ADDRESS:	OCCUPATION: 		
HOME #: 		CELL #: 		WORK #: 		
Number to use for contact:	HOME	CELL	WORK	
Does this parent/guardian have joint custody?
Is this person legally restricted access to the student?	Y
Y	N	Should this parent/guardian receive school information?
N (A copy of the court order must be provided to the school.)	Y	N	

Are you or a member of your household active duty, active reserve or National Guard?	Y	N

PREVIOUS SCHOOL INFORMATION	
NAME OF PRESENT SCHOOL:		GRADE: 	
STREET ADDRESS:		PHONE #: 	
CITY	STATE	ZIP CODE	
FORMER SCHOOLS (LIST IN ORDER)	DATES ATTENDED	

		

SPECIAL SERVICES INFORMATION

Does your child have a current 504 plan?
If yes, please explain: 	

Emotionally Disabled

Learning Disabled

If yes, please specify below:
Speech/Language

Is your child currently receiving or has ever received Special Education Services?

DISCIPLINE	
Please provide discipline information and dates below.
Pending Expulsion	Expulsion Dates:	

All information provided on the enrollment form and/or requests for student records are for informational purposes and/or cohort
placement. Enrollment at Academy of Tucson Schools is open. The Academy of Tucson does not and shall not discriminate on the basis of race, color, religion (creed), gender, gender expression, age, national origin (ancestry), disability, marital status, sexual
orientation, or military status, in any of its activities or operations. Answers provided or missing information does not negatively impact enrollment or enrollment status.
All stakeholders — including students, parents, guardians, teachers, staff, etc. — are expected to support the mission of The Academy in providing the best possible educational outcome for all students.

STUDENT SIGNATURE:

	 DATE: 	

FOR ADMINISTRATIVE USE ONLY:
SMS DATA ENTRY DATE:	WITHDRAWAL DATE: 	

ENTRY DATE: 	

UNIQUE STATE ID#: 		ENROLLMENT CODE: