PA LEARNERS Online Enrollment Form

ONLINE ENROLLMENT FORM

I certify that this application is accurate, true and current. I understand that the information being provided is confidential and will be used only on an as needed basis by the professional staff and will not be made public without parent/guardian permission. I further realize that information provided to PALO cannot and will not be used to screen students for admission. I accept my/our obligation to ensure that all computer equipment and school materials will be cared for responsibly and used appropriately. I agree to be an active, involved partner in my child's Individual Learning Program and to collaborate with administrators and teachers so that my child can fully benefit from the academic opportunities offered by PA LEARNERS Online Regional Cyber Charter School.

I hereby make application to PALO for the admission of my child:

Student Information

First Name
Middle Name
Last Name
Date Of Birth (format: mm/dd/yyyy)
Social Security Number (format: xxx-xx-xxxx)
Gender	MALE FEMALE
Ethnicity (Select up to two)	American Indian/Alaskan NativeAsian/Pacific IslanderBlack-(Non-Hispanic)HispanicWhite-(Non-Hispanic)

Email Address
Telephone (format: xxx-xxx-xxxx)
Address1
Address2
City
State
Zip

School Year
Grade Level
Current Enrollment
Resident School District
Name of School Building
How did you hear about PALO?

Miscellaneous Information

	Do you qualify for Free/Reduced priced lunch in your current school placement?
	YES NO

	Please indicate any relevant health-related conditions.


	Has the student ever been expelled, dismissed, suspended or advised to withdraw by any school or educational agency?
	Yes No
	Reason:

	Is there a sibling or member of your household currently enrolled in PALO?
	YES NO

	If yes, what is that student's name and age?
	Name: Age:

	Was your child receiving special education services though an IEP/504 Plan?
	YES NO


Contact #1 Information

First Name
Middle Name
Last Name
Are You The Guardian?	YES NO
Relation
Email Address
Telephone
Emergency Telephone
Emergency Telephone 2
Address1
Address2
City
Zip


Contact2 Information

First Name
Middle Name
Last Name
Are You The Guardian?	YES NO
Relation
Email Address
Telephone
Emergency Telephone
Emergency Telephone 2
Address1
Address2
City
Zip