Columbus Enrollment Form (14-21 years of age)

The Academy for Urban Scholars High School is a public community school established under Chapter 3314 of the Ohio Revised Code. Students enrolled are required to pass all state mandated assessments as well as complete all other graduation requirements as prescribed by Ohio law.

In order to receive a High School Diploma from The Academy For Urban Scholars, students who have been excused from the compulsory attendance law for the purpose of home education, as defined by the Administrative Code, shall no longer be excused for that purpose upon their enrollment in a community school.

For more information contact the school administration or the Ohio Department of Education.

This form asks applicants for information about themselves, including their educational and family background. Please click in the desired field and fill out the form. After completion sign and submit this form.

Scholar's Last Name *

Scholar's First Name *

Scholar's Middle Name *

Scholar's Birth Date * +

Scholar's Birth City *

Scholar's Birth State *

Scholar's Birth Country *

Scholar's Gender *

Scholar's Grade *

Scholar's Ethnicity *

What is the scholar's primary language? *

Who is the legal parent/guardian? *

Who does the child live with? (for minor children only) *

Guardian must have court custody paperwork (upload here)

Parent/Guardian's Street Address *

City *

State *

Zip Code *

(Proof of residency must match address)

Proof of Residency (Example: Utility bill for the past 30 days)

Proof of Age Birth Certificate Required

Proof of Age ( I.D.) - If the student does not have an ID- Please take a picture and upload it.

Contact Information

Parent/Guardian's Home Number *

Parent/Guardian's Cell Number *

Alternative Number *

Parent/Guardian's Primary E-mail Address *

Is your family homeless? *

Yes

No

Does the scholar receive special education services (IEP)? *

Yes

No

Was the scholar ever retained? *

Yes

No

If you answered "Yes" for homeless you will need to fill out this form.

Which Career Pathway is the scholar most interested in learning about? *

How did you hear about the school? *

If a referral, who were you referred by? *

What was your previous school district? *

What school & location did you previously attend? *

Emergency Contact #1 Name (non-parent) *

Emergency Contact #1 Phone Number *

Emergency Contact #1 Relationship (Aunt, Uncle, Grandparent) *

Emergency Contact #1 Email

Emergency Contact #2 Name (non-parent) *

Emergency Contact #2 Phone Number *

Emergency Contact #2 Relationship (Aunt, Uncle, Grandparent) *

Emergency Contact #2 Email

I hereby authorize your organization, to furnish The Academy for Urban Scholars with court documents, official transcripts, test records, Immunizations, Hearing and Vision records, individualized educational plans (IEP)(ERT), multi-factored evaluation (MFE), student accommodation plan (504), and/or psychological reports. Also, please include my child's most recent subjects, grades, SSID number, and Birth Certificate.

Attn: Admissions/Records Officer

The Academy for Urban Scholars

1808 East Broad St.

Columbus, Ohio 43203

Phone: 614-545-9890 Fax: 614-545-9889 IRN: 012528

Signature *

clear

Date * +

By signing this form I acknowledge that I have read this form and agree that all information I entered is accurate.

*This form and any response to it may constitute a public record, and therefore may be available upon request in accordance with Ohio public records law (ORC 149.43).

See the latest School Report Card for The Academy for Urban Scholars