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                       Student Enrollment Form - Xara Garden School

Xara Learning Village Incorporated
P.O. Box 600616, San Diego, CA 92160
Mark Hinkley, Executive Director

619.255.9580
Fax: 619.255.3286
www.xaraschools.org
welcome@xaraschools.org

Student Information (please print clearly in ink)

                                                                                                                                                                                                                                             
Last Name                                      First Name                                  Date of Birth                Male/Female            School Year              Grade

                                                                                                                                                                                                                                             
Street Address                                                                          City                                  State                                     Zip

                                                                                                                                                                                                                                             
Current School          Current Teacher             School Phone                      School Address

Has student ever been suspended or asked to leave a school permanently? Yes / No   If yes, please explain on the reverse side:

 In order for us to meet your child’s educational needs, answer the following questions. These questions do not effect eligibility or
enrollment:

Does the student have an active IEP for Special Education? Yes / No (If yes, a copy of the IEP must be submitted to complete this application.)

Does the student have an active 504 Disability Plan? Yes / No (If yes, a copy of the 504 Plan must be submitted to complete this application.)

Parent/Guardian Information (please print clearly in ink)

                                                                                                                                                                                                                                             
Last Name                                                      First Name             Male/Female                                  Relationship to Student

                                                                                                                                                                                                                                               
Street Address                                                                          City                                  State                                     Zip

                                                                                                                                                                                                                                               
Home Telephone              Work Telephone              Mobile Telephone                  E-mail Address

 

                                                                                                                                                                                                                                             
Last Name                                                      First Name             Male/Female                                  Relationship to Student

                                                                                                                                                                                                                                               
Street Address                                                                          City                                  State                                     Zip

                                                                                                                                                                                                                                               
Home Telephone              Work Telephone              Mobile Telephone                  E-mail Address

Signature of Parent/Guardian

I certify that the information on this application is true and correct. I understand that XLVI can deny or revoke my
child’s admission/enrollment if any information is found to be incorrect or inaccurate.

I also understand XLVI is a cooperative school of choice, and by signing this application, upon admission I agree to
learn and abide by all policies and procedures outlined in student and parent handbooks.

                                                                                                                                                                                                                                             
Signature                                                                      Print Name                                                                             Date