ALTERNATIVE ACADEMY REGISTRATION FORM

Swartz Creek Community Schools

Name___________________________________________________________________________________
Last First Middle
Present Address___________________________________________________________________________
Street
_________________________________________________ Home Phone ___________________________
City Zip
Current Grade ________ Age ________ Birthdate ______________ S.S. #___________________________

Mother’s Home Phone #________________ Work Phone #________________ Cell #___________________

Father’s Home Phone #________________ Work Phone #________________ Cell #___________________

Stepparent Work Phone #__________________ Cell # __________________

Is Child considered Multi-Racial? Yes ______ No ______ If so please list in priority order1__ 2__ 3__ 4__
5__ 6__
Race (please circle) American Indian/Alaskan Native (1) Asian or Oriental (2) Hispanic (3)
Hawaiian or Pacific Islander (4) Black (not of Hispanic origin) (5) White ( not of Hispanic origin) (6)

School Last Attended ______________________________________________________________________

Building District
_______________________________________________________________________________________
City State County
Health Problems or Concerns ________________________________________________________________

Father’s Name _____________________________________________ Birthplace _____________________

Step Father’s Name ____________________________________________________

Mother’s Name _____________________________________________ Birthplace _____________________

Step Mother’s Name ___________________________________________________

Ward of Court ___________________________________ Guardian ________________________________

Affidavit Notarized _________________________________

With whom does child reside? ________________________________________________________

Parent/Guardian Code ________ (See back of form for code and explanation)

Has your child ever been expelled from school? Yes ______ No_______

Was your child in any special education classes in their previous school? Yes ______ No ______

Did your child ever receive any special education services in the previous school? Yes ______ No ______
Has your child ever attended Swartz Creek Community Schools? _____ Yes _____No
Student will not be eligible to attend school until all completed immunization records are received
Signature of Parent: ________________________________________ Date: _________________
 Parent/Guardian Codes Definition of Racial/Ethnic Categories

Parent/Guardian C ode American Indian or Alaskan Native - A person having origins in

any of the original peoples of North America or who maintains
Father & Mother 1 cultural identification through tribal affiliation or community
recognition.
Father Only 2
Asian or Oriental - A person having origins in any of the
Mother Only 3 original peoples of the Far East, Southeast, Asia or the Indian
Subcontinent. This area includes, e.g.: China, India, Japan,
Father & Stepmother 4
Korea and Samoa.
Mother & Stepfather 5
Hawaiian or Pacific Islander - A person having origins in any of
Legal Guardian(s) 6 the Pacific Islands or Hawaii.

Foster Parent(s) 7 Hispanic - A person of Mexican, Puerto Rican, Cuban, Central

or South American, or other Spanish culture origin-regardless
Grandparent(s) 8 of race.

Other Relative 9 Black -(Not of Hispanic Origin) - A person having origin in any
of the Black racial groups of Africa.
Self 10
White - A person having origins in any of the original peoples of
Other 11 Europe, North Africa, or the Middle East.

_____ I am a resident of the Swartz Creek School District.

_____ I am not a resident of the Swartz Creek School District but I am a pregnant or parenting teen.
_____ Not a resident of Swartz Creek Schools but I have dropped out of the high school in my District of
residence.
_____ Not a resident of Swartz Creek Schools but I am being referred by the Court.
_____ Not a resident of Swartz Creek Schools but I have been suspended or expelled from my District of
residence.

What school district do you live in? _______________________________________________________________

Address Confirmation

I, __________________________________________________________, state that I reside at

_____________________________________________________________________________
Street City State Zip

And am the custodial mother, father, or legal guardian (circle one) of

____________________________________________________________________________
Child’s Name

I understand that falsification of an address for purposes of securing an education for the above
named child will result in immediate removal from Swartz Creek Community Schools.

___________________________________________________ ________________________
Signature of Parent/Guardian Date