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Phoenix Rising Contact Form

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Phoenix Rising Alternative School
Phoenix Rising Contact Form

Contact Information

Student Name *

Parent/Guardian Name *

Address *

Home Phone

Birthdate *

Parent/Guardian Phone *

Apt/Unit

Cell (Guardian)

Age *

Parent/Guardian Email *

Zip Code *

Cell (Student)

Number of Credits

Last Date Attended

Last School Attended

Pending Expulsion/Suspension/Safe Placement?

Other Schools Attended (Please list all schools, including any Placements, OJA, Out of State schools, etc.)

IEP OR Special Education Services? *

Yes

Not Sure

Counseling or Therapy? *

Yes

Not Sure

If yes, where and with whom? *

Pending Court Case? *

Yes

Not Sure

If yes, next court date? *

Probation/Parole? *

Yes

Not Sure

If yes, name & number? *

Parent/Guardian currently or previously incarcerated? *

Yes

Check All That Apply to Student
Off-Track Academically
Pregnancy/Parenting- No Child Care
Babysitting for Siblings
Need Academic Support
Safety Concerns
Suspension/Expulsions
Transportation Issues
Have Medical Concerns/Hospitalized

Incarcerated
Loss/Bereavement
Homelessness
Separation/Loss
Trauma/Witness to Violence
Family Conflict
DHS Involvement
Anger/Depression/Anxiety

Release of Student Records

The undersigned hereby authorizes school # 1 *

The undersigned hereby authorizes school# 2

The undersigned hereby authorizes school# 3

to release copies of the following official records: All school records. immunizations, cumulative file, withdrawal grades, special education information, psychological evaluations, and confidential files for:

Full Legal Name of Student *

Date of Birth *

Current Grade *

Consent for the Release of Confidential Information

Authorizing Person *

Child

Parent or Guardian

Legal Custodian

Other