0701 Targeted Parent/Guardian Enrollment Form

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Email and time stamp from this form verifies that you are completing this form for your child to attend a Targeted program. Targeted Programming is an OPTIONAL program, schools can not assign enrollment without your approval.

Email *

Student Last Name *

Student First Name *

Student Middle Name

Student Birthdate *

YYYY

Student Gender *

Male

Female

Student Age *

Student Grade Level (as of 09/01/2022) *

Student Address, including City, State, and Zip *

Current School of Enrollment *

Does the Student Have an IEP *

Yes

Does the Student Have a 504-Plan *

Yes

Parent/Guardian Name *

Parent/Guardian Relationship to Student *

Parent/Guardian Address, including City, State, and Zip *

Parent/Guardian Home Phone *

Parent/Guardian Lives in Which School District *

Enrollment Date into Targeted Programming *

YYYY

Site of Class *

Signature of Parent/Gaurdian *

Please check the checkbox upon reading the statement *

Email and time stamp from this form verifies that you are completing this form for your child and you recognize that this program is optional

Required

Send me a copy of my responses.

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