Summit Charter Collegiate Academy An International Baccalaureate World School Krista Herrera, Principal 15550 Redwood Avenue Jorge Ramos, Vice Principal Porterville, CA 93257 (559) 788-6440 FAX (559) 788-6444 APPLICATION FOR ADMISSION – Part I Date of Application: __________ Grade for which applying: ☐7th ☐ 8th ☐ 9th ☐ 10th ☐ 11th ☐ 12th School Year: 2015-2016 Applicant’s Name: Date of Birth: Last Name First Name Middle Name Address: _______________________________ Age: ______ Gender: ☐Male City: ________________________________ Zip: ______ Place of Birth: __________________________________ Living with: ☐Mother ☐ Father ☐Both ☐Mother/Stepfather ☐Father/Stepmother ☐ Female ☐Other: ___________________ If other, please list name and relationship: ______________________________________________________________________ Last School Attended: Name of School City/State PARENT/GUARDIAN INFORMATION Father/Guardian Name: Mother/Guardian Name: Mailing Address: Mailing Address: City/State/Zip: City/State/Zip: Email Address: Email Address: Home Phone: Home Phone: Cell Phone: Cell Phone: Work Phone: Work Phone: STUDENT INFORMATION Has your child ever been considered for accelerated or gifted programs? ☐Yes ☐ No If yes, please explain: __________________________________________________________________________________ Does your child have any physical limitations, handicaps, or learning disabilities? ☐Yes ☐ No If yes, please explain: __________________________________________________________________________________ Has your child received any special help in any academic area? ☐Yes ☐ No If yes, please specify: ☐English ☐Math ☐other: ________________________________________________________ Has your child been evaluated for special services? If yes, please specify: ☐Speech ☐Hearing ☐Vision ☐Academics Which academic areas? _______________________________________________________________ Does your child have and Individualized Educational Plan (IEP)? ☐Yes Parent Signature ☐ No Date APPLICATION FOR ADMISSION – Part II To be completed by applicant Are you currently expelled from a school or being considered for expulsion? ☐Yes ☐ No If yes, please explain: __________________________________________________________________________________ Are you currently failing any subject(s)/course(s) at your current school? ☐Yes ☐ No If yes, please explain: __________________________________________________________________________________ Are your having or have you had any behavior problems at your current school? ☐Yes ☐ No If yes, please explain: __________________________________________________________________________________ Why do you want to attend Summit Charter Collegiate Academy? What are your goals for the next school year? What are your long term goals (What do you think you’d like to do when you complete high school? By signing this document, you are attesting to the validity of its content. We reserve the right to revoke enrollment status should we find the content of this document was not reported accurately. Student Signature: _______________________________________________ Date: _____________________ On behalf of Summit Charter Collegiate Academy, I want to thank you for your interest in becoming part of all the GREAT things happening at SCCA! I look forward to meeting you and discovering whether or not our school will be a good fit for you. Sincerely, Krista Herrera, Principal The following documents must be included for the application to be considered complete: ☐ Copy of recent report card ☐ Current attendance record ☐ Copy of recent standardize test scores ☐ Copy of school discipline records ☐ Transcripts (High School Students) ☐ Copy of current IEP, if applicable If you are accepted to SCCA, you will need to provide the following additional documents to the SCCA office: ☐ Copy of Birth Certificate ☐ Immunization records ☐ Legal forms, if applicable (i.e. Guardianship, Custody, Name Change, etc.) ☐ Other district/enrollment forms provided by the school, including the Enrollment Contract, Burton District registration Form, Home language Survey, etc.)