Student Application Form

 Student Information
Student SSN:
Required 
Grade:
 
 Student Legal Name
Last:
Required 
First:
Required 
Middle:
Required 
 
Home Phone:
Required 
 
 Home Address
Number, Street Name, Apartment
Required 
City:
Required 
State:
ZIP:
Required 
 
 Parent Information
Student Lives With:
Required 
Legal Guardian?:
 
 Mother's Information
Mother's Name:
Mother's Email:
Mother's Address:
Home Phone:
Cell Phone:
Mother's Work:
Work Phone:
Work Address:
 
 Father's Information
Father's Name:
Father's Email:
Father's Address:
Home Phone:
Cell Phone:
Father's Work:
Work Phone:
Work Address:
 
 Student History
Birth Date:
    CalendarRequired 
Birth Place:
Sex:
Race:
Parent/Guardian Home Language:
Student's Native Language:
Country/State of Residence:
 
 Please answer the following questions:
 
Is a language other than english used at home?:
If yes, what language?:
 
Did the student have a first language other than English?:
If yes, what language?:
 
Does the student most frequenly speak a language other than English?:
If yes, what language?:
 
Has the student been identified as exceptional education?:
 
 
 Emergency Contact Information
 Emergency Contact #1
Last Name:
Required 
First Name:
Required 
Contact Phone 1:
Required 
Contact Phone 2:
Relationship:
Required 
 
 Emergency Contact #2
Last Name:
First Name:
Contact Phone 1:
Contact Phone 2:
Relationship:
 
 Emergency Contact #3
Last Name:
First Name:
Contact Phone 1:
Contact Phone 2:
Relationship:
 
 Last School Attended Information
Current Grade:
School Name:
School City:
County:
State:
ZIP:
Country:
School Type:
Has your child been staffed into an Exceptional Education Program through the school district?:
Name of the ESE Program(s):
What is your child's primary diagnosis?:
Does your child have an IEP?:
 
 Student Medical Information
Physician's Name:
Phone:
Describe Heath Problems or Allergies:
Medications:
 
 Signature Section
 
 I give permission for my child to be photographed while at school for the purpose of:
Instruction:
Observation:
Information/Advertisement:
 
 
 
 
 
 
Parent/Legal Guardian:
Required 
Date:
    CalendarRequired 
 
 Pickup Information
 The following person(s) may pick up my child from school, other than the parent (identification required)
 
 Person #1
Name:
Phone:
Relationship:
 
 Person #2
Name:
Phone:
Relationship:
 
 Person #3
Name:
Phone:
Relationship:
 
 Signature
Parent/Legal Guardian:
Required 
Date:
    CalendarRequired 
 
 Access Charter School, Inc. does not discriminate in admission or access to, or treatment or employment in its programs and activities on the basis of race, age, sex, national origin, marital status, handicap, or any other reason prohibited by law.
 
 
 To submit this Student Application, please fill out the entire form and then click the Send link below. Please only submit the online application once. We will contact you regarding your application as soon as possible.
 Send

Access Charter School

 321-319-0640

 321-319-0643 (fax)
 info@AccessCharterSchool.org
 6000 East Colonial Dr. Orlando FL. 32807
 

Access Charter School is a 6 – 12 grade exceptional education program designed to meet the needs of students diagnosed with Autism Spectrum Disorder and students with significant cognitive and social skill delays and their families. With a commitment to outstanding academic, vocational, and functional life programs it is our mission to provide each student an educational environment which fosters understanding, compassion, and respect.

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