TWIN RIDGES HOME STUDY CHARTER SCHOOL 2008/2009 Application
Student’s Last Name ________________________________ First Name _____________________________ Nickname ___________________ Grade
(in 08/09)
_______ Birth date __________ Gender:
City Zip
Male
Female
Residence Address: ___________________________________________________________________________
Street (No P.O. Box)
Mailing Address: ______________________________________________________________________________
Street or P.O. Box City Zip County of Residence:
Nevada
Yuba
Sierra
Placer
Other ______________
Primary Phone (
) __________________ Primary Contact’s e-mail _________________________________
Parent/Guardian’s Last Name ________________________________ First Name _________________________ Student History
Where is Student Currently Enrolled?______________________________________________Phone_________________________________ City / State_________________________________________________ Fax____________________________________
Is Student Currently Enrolled In:
Special Ed 504 Plan
YES NO YES NO
Title I GATE
YES NO YES NO
Why are you interested in Twin Ridges Home Study?
__________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________
___________________________________________________________________________________________ When are you interested in enrolling in Twin Ridges Home Study? _____________________________________ Who will be the primary educator for your child? ___________________________________________________________________________________________ ___________________________________________________________________________________________ How Did You Hear About Us?
__________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________
TWIN RIDGES HOME STUDY CHARTER SCHOOL 111 New Mohawk Rd, Nevada City, CA 95959
Phone (530) 478-1815 Fax (530) 478-0266 email: mtaplin@twinridgeshomestudy.org