If you are human, leave this field blank. Applying for (month and year): * Student's Name (last, first, middle) * Grade for fall: * Kindergarten First Second Third Fourth Fifth Student's Date of Birth: * Student's Birth Place (City): * Gender * Male Female Twin/Triplet? * Yes No Student's Primary Residence (Street Address): * City * State * Zip * Home Phone * School District of Residence * Previous School Attended * Ethnic Information (PER MI DEPT of ED). Check All That Apply. * American Indian/Alaska Native Black/African Asian Native Hawaiian/Pacific Islander Hispanic/Latino White Parent/Guardian 1 Name * Relationship to Student * Legal Guardian? * Yes No Street Address (if different from student) City State Zip Home Phone * Cell Phone Work Phone Email Address * Employer/Occupation Parent/Guardian 2 Name Relationship to Student Legal Guardian? Yes No Street Address (if different from student) If yes, what date? Check all services received L.D E.C.D.D. E.I. V.I. H.I. P.I. A.I. O.H.I. T.B.I. C.I. E.S.L. Resource Room Self-Contained Classroom Did the student receive Special Services from previous school? * Yes No Please list all languages spoken at home * Are you sharing the housing of others due to loss of housing, hardship, or a similar reason? Yes No Are you currently residing at a motel, hotel, car or campsite because your home has been damaged or for economic reasons? Yes No Are you currently residing in a shelter? Yes No Are you currently living in a temporary housing arrangement due to economic hardship? Yes Does the student have a sibling(s) currently enrolled at Augusta? * Yes No Name(s) Name(s) and Grade(s) Does the student have a sibling(s) also applying at Augusta? * Yes No How did you find out about Augusta Academy? If referred, please include the individual's name. * Why do you want your child to attend Augusta? * Your Name and Date *
