Registration Form




Please read all instructions as you complete this form in its entirety.
If you have any questions please contact our enrollment team at 484-875-5410.

* Fields with red asterisks are required.
* Fields with blue asterisks are required if applicable.


 
New Student Information

Please enter the prospective student's legal name as it appears on their birth certificate. If the student's name has been changed, legal documentation will need to be provided.

First Name * Middle Last *
Suffix (Jr, II, etc.) Student's Preferred Name Student's Email
Student's Birthdate (mm/dd/yyyy) * Student's Cell Phone #


The following questions are all required:
Are the parent(s)/legal Guardian(s) of this child on active military duty? *
Is there a current custody agreement for this child?*
Currently or at any point during this school year
have/do any of the following apply to your student:*
    • Student is homeless
    • Staying in shelter
    • Living in a car, park, public space or an abandoned building
    • Temporarily living in a motel or hotel due to loss of housing
Was your student ever adjudicated for any of the following reasons:
    • Dependency under 23 Pa.C.S. Ch. 63 (relating to child protective services) and 42 Pa.C.S. Ch. 63 (relating to juvenile matters)
    • Delinquency under 23 Pa.C.S. Ch. 63 and 42 Pa.C.S. Ch. 63, if the parent or guardian of the student wishes to disclose the adjudication of delinquency
    • As part of court-ordered services under a voluntary placement or custody agreement.
Student has completed the Prospective Student Experience?:
Student understands and agrees to expectations on school engagement and school participation?:
Grade Enrolling In * Student Ethnicity *
Sex * Student Race *
Internet Service Information
What type of internet do you have?
Who is your internet service provider (ISP)?
Guardian Information
Student Resides With *
Primary Parent/Legal Guardian Information (No P.O. Boxes)
This should be the parent/guardian whom the student resides with in Pennsylvania, and who will be our primary contact.
   
Type *  
First   
Name * 		Last   
Name *
 
Cell    
Phone * 		Landline *
Email *
 
Address * City *
State * ZIP *
 
Has this parent completed the Prospective Student Experience?:
Does this parent understand and agree to expectations on school engagement and school participation?:
Residential County
Residential District
 
Secondary Parent/Legal Guardian Information (No P.O. Boxes)
This person will be the contact person if the Primary is unavailable
(ie: Mother, Father, Step-parent, etc.).

Type *  
First   
Name * 		Last   
Name *
 
Cell  
Phone 		Landline
Email
 
Address City
State Zip
 
Has this parent completed the Prospective Student Experience?:
Does this parent understand and agree to expectations on school engagement and school participation?:
Emergency Contact - In case we cannot reach you.
Please provide contact information for someone other than a parent/legal guardian in the event that you are unreachable.
Please enter a home or cell phone number for the emergency contact

Full Name *   Relationship *
Primary Phone * Email

Home Language Survey
Country of Student's Birth *
If not born in the U.S., enter the child's date of entry into the U.S.*
Please complete all that apply:
       Is a language other than English spoken in the child's home? * If so, which?
       Does your child communicate in a language other than English? * If so, which?
       What is the language your child first learned to speak?*
       Has the student received English as a Second Language (ESL) services? *
If yes, answer the following:
       What school year did the student begin ESL?*
       What school year did the student complete ESL?*
School Information
Please enter the following information concerning the student's current or most recent school.

During what school year did your child first begin attending Pennsylvania schools? *  
Type of Current School
Current School Attending (OR if not in school, then the last school attended) *
If not attending school, withdrawal date from previous school (mm/dd/yyyy)
Address of Current School
Current School's City
Current School's State *
Current School's Zip
Current School's Phone Number
Current School's Guidance Fax Number
My child would attend the following school if (s)he was attending at the local school district:
Special Services

Does the student receive special education services (IEP, GIEP, 504)? *

I understand and certify that:
1. This application for admission is accurate and current.
2. The information being provided is confidential and will be used only by the professional
    staff and will not be made public without parent/guardian permission.
3. The information provided cannot and will not be used to screen students for admission.




21st Century Cyber Charter School      Toll Free: 877-Web-Cyber (932-2923)      Email: info@21cccs.org