Application Form

ROOTS PUBLIC CHARTER SCHOOL

ONLINE ADMISSION APPLICATION FORM

STUDENT INFORMATION

Select a date

Student's First name

Student's Age

SID

Last name

Date of Birth

Special Services (check any that apply)

Current IEP (Individualized Education Program)

Current 504 Plan

English Learner (ESL)

PREVIOUS SCHOOL INFORMATION

Previous School

Student ID Number

School's email address

School Phone

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

PARENT/GUARDIAN INFORMATION

Name of parent or guardian

Relationship to Child

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Contact Information

Parent/Guardan #1

Home Phone

Work Phone

Cell Phone

P/G#1 email address

Parent/Guardan #2

Home Phone

Work Phone

Cell Phone

P/G#1 email address

Signature of Parent/Guardian

Select a date

Parent/Guardian must sign application in person prior to enrollment!

Thanks for applying to Roots Public charter School