APPLICATION FOR ADMISSION – Part I

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.)