To begin the application and registration proccess, please fill out as much information as possible below before submitting the form. Thank you.

STUDENT INFORMATION

Last Name First Name Middle Initial
Female      Male  
Social Security Number    
Street Address APT # Zip Code
 
Home Phone # Secondary Phone #  
Date of Birth (mm/dd/yyyy) Age Current Grade
Birthplace (Country only) If Not USA, how many years in USA
(1) (2)
Last 2 High Schools Attended  
Out of State School Name Date Last Attended
Student's Employer Name Employer's Phone # Days and Hours Student Works

STUDENT ETHNICITY

Please check your student's
ethnicity from the following list:
(Multiple ethnicities may be
checked if appropriate.)		 Anglo
African American/Black
Hispanic
(of Spanish speaking culture/origin)
American Indian or Alaska Native
Asian or Pacific Islander
Other (type below)
   
In what language do you prefer to be taught?

PARENT INFORMATION

Father's Last Name Father's First Name Father's Middle Initial
Living with this parent?
Yes No 		 Legal Guardian?
Yes No
Street Address Apt# Home Phone #
Quadrant Zip code 2nd Phone #
 
Father's Employer Name Work Phone #  
Mother's Last Name Mother's First Name Mother's Middle Initial
Living with this parent?
Yes No 		 Legal Guardian?
Yes No
Street Address Apt# Home Phone #
Quadrant Zip code 2nd Phone #
 
Mother's Employer Name Work Phone #  

ADDITIONAL INFORMATION

DO YOU HAVE A BROTHER OR SISTER CURRENTLY ATTENDING ATDSCS? Yes No IF YES - WHAT IS YOUR BROTHER’S OR SISTER’S NAME
     
Person whom student lives with if other than mother or father, (H.S. students may include self, spouse, etc)
Legal Guardian? Yes No
Relationship    
Last Name First Name Middle Initial
Street Address APT # Zip Code
EMERGENCY INFORMATION
 

Emergency Contact
(other than parent)

 Phone #  
FAMILY OR PRIMARY CARE PHYSICIAN
Physician's Name Phone #
Is the student covered by health insurance? Yes No
Insurance Company Name
Is the student covered by Medicaid? Yes No
Medicaid number
Have you received any of the following:
1. Services as a Special Education student? Yes No
2. Speech and language Services Yes No
3. Social Work Services Yes No