SEQUOIA CHOICE DISTANCE LEARNING
1460 S. Horne, MESA, AZ 85204
(480)461-3200 EXT. 2280
STUDENT ENROLLMENT
APPLICATION FORM

Date
__________
STUDENT INFORMATION
Student's legal name
Last
______________________________
First
______________________________
M.I.
__

Do you have an email address?
__No
__Yes
Students e-mail address
______________________________

Home address
________________________________________
City
_______________
ST
__
ZIP
__________

Mailing address (if different)
________________________________________
City
_______________
ST
__
ZIP
__________

Gender
__Female
__Male
Home phone no. (xxx-xxx-xxxx)
______________
Language spoken at home
_______________

Birth date (mm-dd-yyyy)
__________
Birth place
________________________________________
State
__
Country
_________________________
Ethnic origin:
__Caucasian/White
__African/American/African
__American Indian/Alaska Native
__Asian/Pacific Island
__Hispanic

Location:
__All About Kids (AAK)
__Academy of Eastern Arizona (AEA)
__Arizona Distance Learning (online)
__Arivaca (Arivaca)
__Circle Of Health (Phoenix)
__DVYWC (Sacaton)
__Indian Wellness (Phoenix)
__Project ChalleNGe (Queen Creek)
__Redwood Academy (Peoria)
__Home School Resource (Show Low)
__Star (Mesa)
__Summerhawk (Douglas)
__Thunderbird Resource Center (Phoenix)
__Sequoia Village (Show Low)
__Family Academic Services (FAS)
Lab advisor
______________________________
Are you on probation?
__No
__Yes
Name of probation officer
______________________________
Probation officer phone
____________

Are you currently enrolled in another program in addition to sequoia choice distance learning labs?
__No
__Yes
Are you enrolling for summer school?
__No
__Yes
Please list course(s) you will be taking
__________________________________________________

Where did you hear about us?
__AZ Central
__Yahoo!
__Google
__MSN.com
__Lycos
__Ask.com
__Other Search Engine, Please specify -->
__Online
__TV
__Friend
__Newspaper
__Radio
__Other, Please specify -->
__________________________________________________


RECORD INFORMATION
Last school attended (please do not abbreviate)
________________________________________________________________________________
Date last attended (mm-dd-yyyy)
__________
Address of last school
________________________________________________________________________________
City
____________________
STATE
__
ZIP
_____

Current grade
__
Last grade completed
__
Number of years in school in the US
__


Previous school attended
________________________________________________________________________________
Date last attended (mm-dd-yyyy)
__________
Address of previous school
________________________________________________________________________________
City
____________________
State
__
ZIP
_____

Current grade
__
Last grade completed
__
Number of years in school in the us
__

I hereby authorize the above referenced school to release the following records to sequoia choice school:
Transcript
Special education records
Cumulative folder
Psychoeducational records
Legal
Health/medical records
Speech/language/audiological


SECONDARY STUDENTS:
Year student entered 9th grade? (XXXX)
____
Has student been expelled or long term suspended from a previous school?
__No
__Yes


If enrolled in another school (and intend to continue dual enrollment)
SCHOOL'S NAME
________________________________________________________________________________
NUMBER OF HOURS
__

You must submit your birth certificate and your immunization records within ten (10) days or provide an explaination of why this is not possible. If you do not comply, we have the option to withdraw you from our program.
I have read and I understand the above requirement.


ARIZONA STUDENT EDUCATION & CAREER ACTION PLANS (ECAP)




Student Username
__________________________________________________
Student Password
__________________________________________________
Program Used:
__AzCIS
__Bridges
__Naviance
__Kuder


FAMILY INFORMATION
Parent/legal guardian (Last, First, Middle)
__________________________________________________
Relationship to student
__________

Parent/guardian email address
(Must be different than student email address)
____________________________________________________________
Cell phone number
(XXX-XXX-XXXX)
____________

Occupation
____________________
Place of employment
____________________
Home phone no.
______________
Work phone no.
______________

Parent/legal guardian (Last, First, Middle)
__________________________________________________
Relationship to student
__________

Email address
(Must be different than student email address)
____________________________________________________________
Cell phone number
(XXX-XXX-XXXX)
____________

Occupation
____________________
Place of employment
____________________
Home phone no.
______________
Work phone no.
______________

Annual Notification to Parents Regarding Confidentiality of Student Education Records
Notificación Anual a los Padres con Respecto a la Confidencialidad de los Expedientes Académicos de los Estudiantes
I have read the family education and privacy act

TEMPORARY PLACEMENT FOR SPECIAL EDUCATION PROGRAMS
Is the student currently enrolled in special education services?
__No
__Yes
Has the student ever been enrolled in special education services?
__No
__Yes

If YES, what is the date of the last I.E.P.
__________
Please provide a current copy of the I.E.P.


Does the student currently have a 504 plan?
__No
__Yes
Has the student ever had a 504 plan?
__No
__Yes

If YES, what is the date of the last 504 plan?
__________
Please provide a current copy of the 504 plan

I
__Do
__Do Not
give my permission for my child to receive special education support services


STUDENT HEALTH INFORMATION
Are there any special medical, educational, parent custody or other considerations the school should be aware of?
______________________________________________________________________
______________________________________________________________________

Has student had any of the following:
Auditory processing problem
Hearing impairment
Kidney disease
Epilepsy/seizures
Speech problems
Allergies
Diabetes
Visual problems
Wears glasses
Head injury
Heart disease


Is the student taking medication?
______________________________________________________________________
Is the student under treatment for any physical disorder?
______________________________________________________________________
Has student completed immunizations required for school enrollment?
__No
__Yes
__Unsure

Closest living relative
________________________________________
Relationship
____________________
Phone no. (XXX-XXX-XXXX)
____________

Emergency contact
________________________________________
Relationship
____________________
Phone no.
____________


HOME LANGUAGE INFORMATION
What is the primary language of the student?
_______________
In what language would you prefer school communication?
_______________

I have read the notice to parents


SCHOOL PHOTO/VIDEO PERMISSION
I hereby grant permission for my child to be photographed or videotaped in any school related article, brochure, video production, or other publication.
__No
__Yes


McKINNEY-VENTO ELIGIBILITY
This portion of the enrollment form is intended to address the McKinney-Vento Act 42 U.S.C. 11432. The answers to this residency information help determine the services the student may be eligible to recieve

Is your current address a temporary living arrangement?
__No
__Yes
Is your temporary living arrangement due to a loss of housing or economic hardship?
__No
__Yes

If you answered YES to the above questions, please complete the remainder of this section.
If you answered NO, you may skip to the next section.

Where is the student presently living?
__In a motel
__In a shelter
__With more than one family in a house or apartment
__Moving from place to place
__In a place not designated for ordinary sleeping accommodations (ex: car, park, campsite)
Please send a copy to McKinney-Vento Liaison
Liaison Name:______________________________


CONTRACT OF EXPECTATIONS
Our School is dedicated to providing a safe, nurturing atmosphere of respect that fosters the love of learning. A parent or guardian must be present to supervise their student's academic work. Please read and discuss these guidelines with your child. Your signature below demonstrates your approval of this contract and your willingness to uphold and abide by it. Both you and your student must sign and submit the enrollment forms.
Expectation #1: Students will respect and obey the law.
Any illegal activity occurring while participating in any school activities, while with other students, or with school property will be met with zero tolerance resulting in immediate suspension or expulsion. These activities include, but are not limited to,: possession or use of tobacco or alcohol; activities related in any way to the purchase, use, or possession of drugs; gang related activities; possession of weapons; or abuse. Theft, vandalism, or other mistreatments of property belonging to others (including the school) will result in consequences which may range from an informal conference to expulsion, and may include restitution of stolen or damaged items or police involvement.

Expectation #2: Students will respect the ideas, beliefs, cultures, and individual differences of others.
Students engaging in verbal or written abuse, intimidation, harassment, discrimination, disrespect of authority, fighting, profanity, obscene behavior, extortion, gang-related activities, or other such behaviors will receive consequences ranging from an informal conference to expulsion based on attitude, severity, and prior history.

Expectation #3: Students will respect the privilege of education.
Plagiarism, lying, cheating, dress code violation (when on campus and/or participating with others in school activities), public displays of affection (when on campus and/or participating with others in school activities), or any form of academic misconduct will result in consequences ranging from an informal conference to expulsion based on attitude, severity and prior history.

Expectation #4: Students will have the ability to use a computer daily.
All students must have daily access to a computer with Internet access and must have the basic computer skills needed to use a computer. Students and parents both must be familiar with and know how to operate a windowed environment. Email skills, including receiving and sending attachments, are required. Minimal typing skills are also essential. Most importantly, students and parents should not be afraid of the computer or learning new technology. We recommend high speed internet access and a Pentium II class 300 MHE or greater, 64 MB RAM, 16X or greater CDROM, 15" or greater monitor, mouse, comfortable keyboard, 2GB+ of hard drive space. The most basic computer required would be a Pentium 233MMX, with sound, 32MB RAM, CDROM, with a modem, monitor, mouse and keyboard.

Expectation #5: Students will be responsible citizens of the Internet.
Students and parents/guardians must agree to abide by the following as users and citizens of the Internet ("netizens"):
  1. I recognize and accept the responsibility for my actions and conduct on the Internet.
  2. I will not participate in any type of inappropriate behavior while online. Inappropriate behavior includes, but is not limited to, accessing, viewing and/or distributing vulgar or demeaning language, images and/or audio, hacking, damaging and/or altering software, data and/or hardware so as to harm and/or inconvenience others.
  3. I will be courteous and respectful of property (including, but not limited to, data, programs and/or information) and people on the Internet.
  4. Sequoia Choice computer and Internet resources will not be used for commercial purposes without prior written consent of Sequoia Choice Governing Board.
  5. Use of the Internet and computers of Sequoia Choice is a privilege, not a right. Abuse and/or misuse of that privilege may result in loss of that privilege and/or other academic and/or disciplinary action.
  6. Parents and students recognize that Sequoia Choice School can do nothing about and is not responsible for filtering incoming Internet e-mail nor the content of chat groups or news groups. We suggest that parents monitor computer use carefully.

Expectation #6: Parents/Guardians realize that upon student enrollment, they become active participants in a "technology assisted" educational program sponsored by Sequoia Choice and chartered by the State of Arizona.
  1. Parents/Guardians work closely with teachers in developing an individual instruction plan, which includes a variety of educational opportunities and experiences assisted by technology.
  2. Students whose parents/guardians fail to communicate or responsibly work with teachers and staff for the benefit of their student(s) may be withdrawn from the program. Parents and students should check the school site and their email daily.
  3. Upon withdrawal or termination from the program, parents/guardians agree to return all school materials within two weeks. No transcripts or school records will be sent to other schools until materials are returned and attendance records are current within the enrollment period.
  4. Parents/Guardians are responsible for ensuring that they are connected to the Internet. If an Internet connection is down, it is the parent's/guardian's responsibility to contact the school to inform us. the student's computer is expected to be online again as rapidly as possible.

Expectation #7: Parents/Guardians will monitor attendance.
Educational hours are tracked in the categories set forth in the Arizona State Standards. Failure to submit attendance on a weekly basis may result in probation, which may lead to withdrawal of the student. Transcripts and grades will not be issued if attendance is not current. Attendance may be submitted through the Internet, fax, mail, or a parent may phone in. (Please use 480-461-3200) Fulltime students need to log the following educational hours:

Grades 7-8 = 30 hours per week
Grades 9-12 = 25 hours per week

Parent is legally responsible for attendance and reporting it. - you may call 480-461-3200 to do so.
Expectation #8: Parents/Guardians will be responsible for student transportation.
Parents must provide transportation to the campus whenever necessary to complete tests and/or all other requirements. These requirements include AIMS testing, Stanford testing, hearing screenings, and placement tests. It may also be necessary to transport your student(s) to participate in optional field trips or activities.

High School Students - Please read this notice carefully:
Sequoia Choice does not discriminate in its enrollment policy. Students applying for enrollment may be tested to determine appropriate placement regardless of age or prior grade level. If it is determined that a student is not ready for high school courses, it will be necessary to give them appropriate curriculum for their level.

I have read this contract of expectations and agree to be subject to its guidelines while participating in any school activities. I further recognize that I will be held responsible for my actions according to this contract and the consequences herein. By typing in my name on the line below I recognize that it constitutes my signature and is legally binding. I also certify that I have educational rights for the student I am enrolling. PARENT/GUARDIAN'S NAME
________________________________________
STUDENT'S NAME
________________________________________