Southwest Leadership Academy

Intent to Enroll 2021-2022*

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Date*

Student Name*

First Middle Last

Age*

Birth Date*

2021-2022 Grade*

Student Email*

Student Phone*

Parent/Legal Guardian Name*

Prefix First Last

Parent Email*

Home Address*

Street Address Address Line 2 City State ZIP Code

Home Phone*

Mobile Phone*

Work Phone*

Is your student currently enrolled in school?*

Yes
No

If yes, which school?

Is your student passing their classes?*

Yes
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Is this a summer enrollment?*

Yes
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Last school attended:*

Withdrawal Date*

Reason for leaving last school:*

Is the student a primary caregiver or financially responsible for dependents and, therefore, may require a flexible school schedule?*

Yes
No

If yes, explain:

As a primary caregiver, does the student require daycare for a dependent 0-5 years of age?*

Yes
No

If yes, explain:

Have you ever been found responsible for a disciplinary violation at any educational institution you have attended, whether related to academic misconduct or behavioral misconduct, which resulted in your probation, suspension, removal, dismissal, or expulsion from the institution?*

Yes
No

If yes, explain:

Currently on:*

Probation
Parole
N/A

IEP:*

Yes
No

Date of Most Current IEP

ELL:*

Yes
No

Additional Comments:

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