2011 HBCP New Student Enrollment Application

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2011 -2012Student Application

Please return completed and signed application along withsupporting documents to:

Hardy Brown College Prep190 Carousel Mall

San Bernardino , CA 92401

Hardy Brown College Prep Line: (909) 884-1410

Required Supporting Documents

Copy of Birth Certificate

Copy of Immunization Records Residence Verification ( i.e. Utility Bill, Mortgage or Rental Agreement) Copy of Report Card, and Discipline Record from Current School Copy of STAR test results from current school (if applicable) Report of Health Examination for School Entry (Kindergarten) Copy of Current IEP or 504 (Special Education) Copy of Valid California Drivers License

Personal/Demographic Information (please print neatly)School Year applying fo r: 2011 - 2012 Grade Applying For: (Circle One) K 1 2 3 4 7

Students Last Name First Name Middle Initial

(Residence) Street Address City State Zip

(Mailing) Street Address City State Zip

Primary Phone # Secondary Phone # Date of Birth (MM/DD/YY)

Present Home School of Attendance / Home School District Gender: Male / Female SSN:

Has the student ever enrolled at Hardy Brown College Prep?

YES or NO (Please circle)Years Enrolled in California Schools:

Mother/Guardians Last Name First Name Middle Initial


Home Telephone #Cell Phone #

Work Telephone #

Occupation Employer

E-mail Address:

Education Level (Circle One): Not a High School Graduate High School Graduate Some College or Associate DegreeCollege Graduate Graduate Degree or Higher Decline to State

Father/Guardian Last Name First Name Middle Initial


Home Telephone #Cell Phone #

Work Telephone #

Occupation Employer

E-mail Address:

Education Level (Circle One): Not a High School Graduate High School Graduate Some College or Associate DegreeCollege Graduate Graduate Degree or Higher Decline to State

Office Use Only

Date Received: ___________


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Day Care Information (if applicable)Day Care ProviderName Work Telephone #

Cell Phone #

Street Address City State Zip

E-mail Address:

Emergency Contact InformationFirst Contact/ Last Name First Name Telephone #

Cell Phone #Relationship


E-mail Address:

Second Contact/ Last Name First Name Telephone #Cell Phone #

Relationship


E-mail Address:

Medical Information

Insured/ Last Name First Name M.I.

Name of Health Insurance Medical ID # / Policy # Telephone #

Allergies Medical Problems/Chronic Illness Other Issues

Doctors Last Name First Name Telephone #

Home Language Survey Which language did your son or daughter learn when he or she first began to talk?

What language does your son or daughter most frequently use at home?What language do you use most frequently to speak to your son or daughter?

Name the language most often spoken by the adults in the home.

Was your child previously enrolled in ESL / Bilingual Program?

Name(s) of Brothers and Sisters Last Name First Name M.I. Gender Current School Grade Level

Instructional Programs InformationHas your child ever been retained? If so, what grade?

Has your child ever been enrolled in any type of special program? If yes, answer questions below.

Please complete the following only i f your child has been enrolled in any type of special instructional programs at his/her previousschool(s):

Has your child ever received resource specialist program services?

Has your child ever received speech services?

Has your child ever been in a self-contained special education class or learning center?

Has your child been GATE identified?

Does your child have a current IEP or 504? If Yes, please submit copy of current IEP or 504 with application.


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COMMITMENT TO EXCELLENCE CONTRACT

TEACHERS COMMITMENT

We fully commit to Hardy Brown College Prep in the following ways:o We will be prepared to teach and be in our classrooms every day by 7:30 a.m.o We will maintain professional standards for appearance and a positive attitude.o We will always teach in the best way we know how, and we will do whatever it takes for our students to learn.o We will work collaboratively with fellow teachers, our Principal and all support staff.o We will always make ourselves available to students and parents, and listen to any concerns they might have.o We will always protect the safety, interests and rights of all individuals in the classroom.

_______________________________ ____________________________________TEACHER SIGNATURE DATE

PARENTS/GUARDIANS COMMITMENTWe fully commit to Hardy Brown College Prep in the following ways:

o We will make sure our child is in the classroom every day by 7:45 a.m.o We will make arrangements so our child can remain at HBCP until his/her grade-level dismissal time.o We will pick our child up on time upon dismissal from school.o We will ensure that our child attends any required HBCP after school, intersession and/or summer school sessions.o We will always help our child in the best way we know how, and we will do whatever it takes for him/her to learn. This also

means we will check our childs homework every night, let him/her call the teacher if there is a problem with the homework, readwith him/her every night, and provide 40 hours of approved family service.

o We will always make ourselves available to our children, the school, and any concerns they might have. This also means that ifour child is going to miss school, we will notify the HBCP office as soon as possible, and we will read carefully all the papers thatthe school sends home to us.

o We will allow our children to go on HBCP field lessons.o We will make sure our child wears the HBCP uniform and follows the HBCP dress code.o We understand that our child must follow the HBCP rules so as to protect the safety, interests, and rights of all individuals in the

classroom. We, not the school, are responsible for the behavior and actions of our child.o We will always protect the safety, interests and rights of all individuals in the classroom. I acknowledge that failure to adhere to

these commitments can cause my child to lose various HBCP privileges, and can lead to my child returning to his/her homeschool.

_______________________________ ____________________________________PARENT SIGNATURE DATE

STUDENTS COMMITMENTWe fully commit to Hardy Brown College Prep in the following ways:

o I will be in my classroom and ready to learn every day by 7:45 a.m.o I will remain at HBCP until my grade-level dismissal time.o I will attend any required HBCP before/after school, intersession and/or summer school sessions.o

I will always work, think, and behave in the best way I know how, and I will do whatever it takes for me and my fellow students tolearn. This also means that I will complete all my homework every night, I will call my teacher if I have a problem with thehomework or a problem with coming to school, and I will raise my hand and ask questions in class if I do not understandsomething.

o I will always make myself available to my parents, my teacher, and any concerns they might have. If I make a mistake, thismeans I will tell the truth to my teacher or Principal and accept responsibility for my actions.

o I will always behave so as to protect the safety, interests and rights of all individuals in the classroom. This also means that I willalways listen to all my HBCP teammates and give everyone my respect.

o I will wear a HBCP uniform and follow the HBCP dress code.o I am responsible for my own behavior, and I will follow my teachers directions. I understand that failure to adhere to these

commitments can cause me to lose various HBCP privileges, and can lead to returning to my home school. _______________________________ ____________________________________STUDENT SIGNATURE DATE


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2011 HBCP New Student Enrollment Application

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Transcript of 2011 HBCP New Student Enrollment Application