PINE FOREST CHARTER SCHOOL

1120 W. Kaibab Lane, Flagstaff AZ 86001

(928) 779-9880 / 779-9792 (FAX)

ENROLLMENT INTEREST FORM

Student Name Today's Date

Mailing Address City State

Zip Code Home Phone Birth Date Student’s Age

Current Grade Birthplace Gender

Email Address:

Grade Enrolling for Date of potential enrollment

Mother’s Name Home Phone

Address City Zip

Business Name Work Phone

Father’s Name Home Phone

Address City Zip

Business Name Work Phone

Parents: Married Separated Divorced Other

If separated, divorced or other than legal parents, who has legal custody of the child?

(You are responsible for providing us with necessary legal custody papers).

Names and ages of other children in the family:

Name of last school attended:

Address Dates

Please check one of the following as required by the Office of Civil Rights.

Caucasian (white) Hispanic Asian or Pacific Islander

African American (black) Native American or Alaskan

Student’s Primary Language Primary Language Spoken in home?

Has the student been in special education class, gifted, bilingual or received any other special services (i.e. NAU Speech Clinic, AZEIP)?

No Yes If yes please specify:

Will the student be staying in our Kinder Care (12-3pm) or After School Care program (3-6pm, 1^st- 8^th grade only)?

(Fee Charged) No Yes

How did you learn about our school?