Students Last Name, First Name, Middle Initial:

Today's Date:

Students Gender: Male or Female

Emergency Contact Name and Phone Number:

Parent/Guardian's Full Name and Relation to the Student:

Mailing Address: (Complete with City, State and Zip Code)

Home Phone Number

Parent/Guardian's Cell:

Parent/Guardian's Work Number:

Student's Phone Number:

Parent/Guardian's Email:

Student's Email:

Student's Date of Birth and Age:

Current Grade (By Credits) 9 10 11 12

Special Education Services:Yes or No (Date/Location of Last IEP)

Last School Attended and Last Date Attended

Do you have a copy of your Transcript? Yes or No

Bilingual: Yes or No Primary Language:

Does the student speak, or understand, a language other than English? Yes or No

Does the student have a child? Yes or No

How did you hear about CCCS?

Parent/Guardian's Signature: Type Name and Date Here

Student's Signature: Type Name and Date Here

I verify that my student will complete skills assessment tests for math and reading before final registration.
I verify that my student plans to attend Cesar Chavez Community School this August 2020.
I verify that I will return to formally enroll my student for the 2020-21 school year and I will contact the school as soon as possible if I decide to remove my student from Registration at CCCS.
Jump start day for new students will be Friday, August 7, 2020.
If you have any questions please contact (505) 877-0558 or email Karina at .