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URSA Enrollment Application Form
Must be a Kansas resident to enroll. Each application will be reviewed prior to acceptance. Acceptance into URSA will be determined by the URSA directors and coordinator.
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* Indicates required question
Student First Name:
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Your answer
Student Middle Initial:
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Your answer
Student Last Name:
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Your answer
Maiden Name or Other Names Used:
Your answer
Enrollment Type
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New Student
Returning Student
Student Phone Number:
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Your answer
Student Email
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Your answer
Address: (Street, City, State, Zip)
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Your answer
Date of Birth: (MM/DD/YYYY)
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Your answer
Gender:
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Male
Female
Age:
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Your answer
Ethnicity:
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White
African
Asian
Indian
Pacific
Other:
Hispanic or Latino:
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Yes
No
Employed?
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Yes
No
Last Grade Completed?
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Your answer
Former School: (Name, City, State)
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Your answer
I give URSA permission to request, transfer or discuss my school records with other schools or post-secondary choices.
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Yes
No
Why are you interested in leaving your current schooling option?
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Your answer
21 & Under: Do you currently have an IEP?
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Yes
No
Services provided under your current IEP? (Check all that apply)
Resource Room
Extra Time on Tests
Reading
Math
Behavior
Parent/Guardian Email:
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Your answer
Parent/Guardian Name:
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Your answer
Parent/Guardian Phone:
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Your answer
Do you have a probation officer?
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Yes
No
Do you have a caseworker?
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Yes
No
Do you have a computer?
Yes
No
Clear selection
Do you have internet service?
Yes
No
Clear selection
By submitting this form, I am providing my digital signature agreeing that the information given on this form is true, complete and accurate. Please type inital:
*
I agree.
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This form was created inside of USD 506 Labette County.
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