Enrollment Application

Please read all instructions as you complete this form in its entirety. If you have any questions please contact Lou Corominas at 484-875-5464.

*The asterisk fields are required.
*This information is required under certain conditions.

Student Information

Please enter the prospective student's legal name as it appears on their birth certificate. If the student's name has been changed, legal documentation will need to be provided.

First Name*
Middle Name
Last Name*
Suffix (Jr, II, etc.)
Student's Birthdate (mm/dd/yyyy)*
Student Ethnicity*
Student Race*
Grade Enrolling In *
Sex*

School Information

Please enter the following information concerning the student's current or most recent school.

During what school year did your child first begin attending Pennsylvania schools?*
Type of Current School*
 
Current School Attending (OR if not in school, then the last school attended) *
If not attending school, withdrawal date from previous school (mm/dd/yyyy)
 
Address of Current School*
Current School's City*
Current School's State*
Current School's Zip*
Current School's Phone Number*
- -
Current School's Guidance Fax Number
- -
Upon enrollment with 21st Century, if the student were to attend your local district, what school building would the student be in?*

Internet Service Information

Please share with us information about how you access the internet.

What type of internet do you have?*

If you currently do not receive internet service, a BeeNet dialup account can be provided for you. If you choose to use BeeNet, you will not qualify for internet reimbursement.

Do you need a BeeNet account?*
If you selected "Needs Dial-up", please provide the
landline phone number from which you will be calling BeeNet.
*
- -

Residential Information (No P.O. Boxes)

Residential County*
Residential District*
Student Resides With*
 
Address*
City*
State*
Zip*
Home Phone*
- - Additional Contact Info - -

Package Shipping Address (Only if different from street address)

Address
City
State
Zip
Shipping Phone
- - Shipping Name

Letter Mailing Address (Only if different from street address)

Address
City
State
Zip

Primary Parent/Legal Guardian Information

This should be the parent/guardian whom the student resides with in Pennsylvania.

Type*
   
First Name*
Last Name*
Work Phone
- -
Cell Phone*
- -
Email

Secondary Parent/Legal Guardian Information

*Enter this information if the child has a secondary parent.

Type*
 
First Name*
Last Name*
Address*
City*
State*
Zip*
Email
Home Phone*
- -
Cell Phone*
- -
Work Phone
- -

Forbidden People

The following person(s) are forbidden by court order to have information released to them about my child unless I have granted specific written authorization. Legal documentation is required.

Full Name Relationship
Full Name Relationship

Emergency Contact

Please provide contact information for someone other than a parent/legal guardian.

*Please enter a home or cell phone number for the emergency contact

Full Name*
Relationship*
Home Phone*
- -
Cell Phone*
- -
Work Phone
- -
Email

Family Size and Annual Family Income

Please provide the following information as required by the Pennsylvania Department of Education. See below for directions in determining these numbers.

Family Size*
Annual Family Income*
$

Family Size: Include all people living in your household, related or not (such as grandparents, other relatives, or friends). You should include yourself and all children who live with you.

Total Annual Family Income: Include the following in the total annual family income:

  • Income from all jobs held by adult members of the household as well as children who contribute to the household income and expenses.
  • Social Security, Pensions, or Retirement
  • Unemployment, Disability, or Worker's Comp
  • Welfare Payments
  • Child Support or Alimony
  • Other income (such as rental income)
  • What if my income is not always the same? List the amount that you would normally get. For example, if you normally get $1000 each month, but you missed some work last month and only got $900, put down that you get $12000 per year (12 x $1000/mo.) If you normally get overtime, include it, but not if you get it only sometimes.


    Home Language Survey

    Country of Student's Birth*
    If not born in the U.S., enter the child's date of entry into the U.S.*
     
    ESL Services Assessment*
       
    Please complete all that apply:  
    What language does the student speak most at home?*  
    Has the student received English as a Second Language (ESL) services? *
    If yes, answer the following:
    What school year did the student begin ESL?*
    What school year did the student complete ESL?*

    Special Services

    Does the student receive special education services (IEP, GIEP, 504)?*
    Yes No
     
    Has the student been suspended or expelled for disciplinary purposes within the last two years?*
    Yes No
     
    Please indicate any health considerations regarding the student.

     
    Please indicate any special needs or interests of the student.

     
    How did you become aware of the 21st Century Cyber Charter School?
     


    I understand and certify that:
    1. This application for admission is accurate and current.
    2. The information being provided is confidential and will be used only by the professional
    staff and will not be made public without parent/guardian permission.
    3. The information provided cannot and will not be used to screen students for admission.


    Please be sure to click submit only once.

     

    Toll Free: 877-Web-Cyber (932-2923)
    Email: info@21cccs.org