Please fill in the form below, print, sign and drop off at Open Doors or email to kfuega@cloverpark.k12.wa.us
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Release to Enroll in Open Doors Reengagement Program 2017-2018

Student Information

Full Name: Birthdate:
Address: City: Zip:
Parent/Guardian Name(s): Home/Guardian Phone:
Parent/Guardian Email: Student Phone:
Current or Last School Attended: In the school district
Location of Last School: City State
Last year attended: Last Grade attended:

Program information

Is the student currently suspended or expelled from a previous school? Yes No
Is the student enrolled or has the student been previously been in Special Education? Yes No
Has the student had a 504 Plan? Yes No
Has that student ever had an IEP? Yes No
Is the student currently on probation? Yes No

Schedule Preference (select a first and second choice):

AM Part Time: M-F 7:25am - 10:30 am (morning transportation only)
PM Part Time: M-F 11:00am - 2:10pm (afternoon transportation only)
Less than Part Time/Special Schedule (special circumstances)
Days: Times:
Online Only. (No transportation, enrolled with Graduation Alliance)

Education Goal(s):

High School Diploma
GED
Skills improvement and transition to work/college/technical school/apprenticeship

Additional Information or special circumstances


It is understood that we as parents/guardians/adult student 1). Will assume responsibility for adequate transportation and supervision to and from the Open Doors Program, and 2) Retain the right for the student to re-enroll in a traditional high school within the district per district guidelines, thus voiding this release. District guidelines state that once a student has been in the program for more than ten (10) days, they may not be eligible to enroll in a traditional CPSD program until the next semester window.


Parent/Guardian/Adult Student Signature

Student Signature

Date