Arizona Cultural Academy
ACA Registration Form
Arizona Cultural Academy
7822 S 42nd Place
Phoenix, AZ 85042
http://www.azacademy.org
Student Information
*
First Name
Middle Name
*
Last Name
*
Gender
M
F
Last Grade Attended
*
Age
Birth Date
City of Birth
State of Birth
Country of Birth
*
Telephone Number
Previous School Information
*
Previous School Attended
*
School Phone
Withrawal Date
School Address
Parent/Guardian Information
*
Father's Name
*
Mother's Name
*
Address
Address 2
*
City
*
State
*
Zip
Phone
Alternate Phone
*
Email Address
Student Background
*
Language Spoken in House
Arabic
English
Other(Please specify)
*
Ever been expelled from another school ?
Yes
No
*
Attended Islamic School before?
Yes
No
*
Language Preferred for Correspondence
Arabic
English
Other(Please specify)
Date Student started School in the US
Ethnic Background
Asian
North African
African American
White
Hispanic
Native American
*
What special services has your child received?
Special Education/Handicaped
Remedial Reading
Remedial Math
Speech/Language
Title I
Other(Please specify)
Most recent school attended
Address
Year
Grade
*
Indicates Response Required
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