Online Enrollment Application
 
Please type in ALL of the information requested below and then press submit at the bottom of the application. We may have to ask you to redo this application, if necessary information is missing.
 
Student Enrollment Application for the
of the
School Year
 
 
STUDENT INFORMATION
 
Birth Date
 
  
Grade Level When Beginning at RAI?
Birth Place (City, State, Country)
   
Student's Last Name
First Name
Middle Name
     
XXX-YYY-ZZZZ
AAA-BB-CCCC
Student's Home Phone Number
Social Security Number
     
Student's Home Street Address
City
State
Zip Code
     
Current School Name
XXX-YYY-ZZZZ
XXX-YYY-ZZZZ
Current School Phone Number
Current School FAX Number
     
Current School Street Address
City
State
Zip Code
 
 
PARENT GUARDIAN (1) INFORMATION
Last Name of Parent/Guardian (1)
First Name
Middle Name
     
XXX-YYY-ZZZZ
XXX-YYY-ZZZZ
Home Phone Number
Work Phone Number
     
No
XXX-YYY-ZZZZ
XXXXXXXX@YYYYYYY.ZZZ
Cell Phone Number
Email Address
     
Mailing Address
City
State
Zip Code
 
 
PARENT/GUARDIAN (2) INFORMATION
Last Name of Parent/Guardian (2)
First Name
Middle Name
     
XXX-YYY-ZZZZ
XXX-YYY-ZZZZ
Home Phone Number
Work Phone Number
     
No
XXX-YYY-ZZZZ
XXXXXXXX@YYYYYYY.ZZZ
Cell Phone Number
Email Address
     
Mailing Address
City
State
Zip Code
 
 
EMERGENCY INFORMATION
Last Name of Emergency Contact (other than Parent/Guardian)
First Name
Middle Name
     
Emergency Contact Relationship
XXX-YYY-ZZZZ
XXX-YYY-ZZZZ
 
Home Phone Number
Work Phone Number
     
 
 
XXX-YYY-ZZZZ
XXXXXXXX@YYYYYYY.ZZZ
 
Cell Phone Number
Email Address
     
Mailing Address
City
State
Zip Code
     
 
Doctor's Name
Doctor's Phone Number
 
     
No
 
Does this student have any allergies, medical problems, or regular medications?
If Yes, please explain.
  
     
     

In the event of an emergency, I do hereby consent to whatever x-ray, examination, anesthetic, medical, surgery, dental diagnosis, or treatment and hospital care are considered necessary in the best judgment of the attending physician, surgeon, or dentist and performed by or under the supervision of a member of the medical staff hospital or facility furnishing medical or dental services. I agree to pay for services or hospitalization rendering. You must choose one or the other.
No
  If not, what action would you like to be taken?
 
 
CLASS SCHEDULING INFORMATION
Current Math Class
Current Science Class
Current English Class
     
Current History Class
Current Elective
Current Elective
     
Other Class
Other Class
Other Class
 
 
SUPPLEMENTARY INFORMATION
Special Services or Programs?
How did you hear about RAI?
 
Gifted and Talented (GATE)
 
English Language Learner
 
Title I
 
Special Ed (SDC)
 
AVID
 
Resource Specialist
 
Migrant
 
Speech / Language
 
ED (Emotionally Disturbed)
 
Have an IEP
Language student's first learned to speak?
 
Language most frequently spoken by student at home?


No
School:
Date:
Has the student ever been expelled from school?
 
No
Officer:
Has the student ever been on probation?
 
Household Size
Total Monthly Income
 
 
 
Friend
 
Flyer
 
Newspaper Ad. Which paper?
 
   
 
TV Advertisement. Which Station?
 
   
 
Radio. Which Stations?
 
School Referred Me. What School?
 
   
 
Other:
   
     
Ethnicity
Race (Please check up to 5 racial categories)
 
Chinese
 
Japanese
 
Korean
 
Vietnamese
 
Asian Indian
 
Laotian
 
Cambodian
 
Hmong
 
Other Asian
 
Hawaiian
 
Guamanian
 
Samoan
 
Tahitian
 
Other Pacific Islander
 
African American or Black
 
American Indian or Alaskan Native
 
White
     
     
     
     
Residence
Highest Education in Household?
 

 

 
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