 BIRTH CERTIFICATE
 Health Appraisal
 IMMUNIZATION
__ IEP if applicable
 REPORT CARD
 I.D.
Staff Initials ___________ only if complete
2017/2018 1st through 8th Grade Application
Instructions:
1. Complete an application for each student you are enrolling in the district.
2. Complete all information on front and back of the application, and include a copy of birth certificate, immunization
records, report card, test scores, disciplinary history and IEP if applicable.
3. Incomplete Applications will not be considered.
The Detroit Service Learning Academy District (DSLA) is a tuition free charter school. No admission tests are needed. DSLA
will serve students in grades K-8 that is a representation of Michigan’s diversity.
The Board of Directors of the Service Learning District does not discriminate in its student admission procedures or course
offerings provided to any student on the basis of race, sex, color, creed, national origin, religion or handicapping condition as
required by Title VI of the Civil Rights Act of 1964, Title IX of the Education Amendments of 1972, Section 504 of the
Rehabilitation Act of 1973, the Age Discrimination Act of 1975, Title II of the Americans with Disabilities Act of 1990 and the
individuals with Disabilities Education Act (IDEA 1997).
Student’s Grade Academic Year 2017/18: K
1st
2nd
3rd
4th
5th
6th 7th 8th
STUDENT INFORMATION
_________________________________________________________________________________________________
Last Name
First Name
Middle Name (not initial)
_________________________________________________________________________________________________
Address
City
ZIP Code
_____/________/________ Age____  Male
Birth Date
 Female
Race: __ African American ___ Native American __ Caucasian ___ Multi Racial ___ Hispanic/Mexican American
__ Asian American
District of Residency:
Other: ___________________
__ Wayne
Is your family currently homeless? ___Yes
___ Oakland
___ Macomb
__ Other _________________
___ No
If the student is NOT living in permanent housing, proof of residency and other documents normally needed are not required
and the student is to be immediately enrolled. After the student has been enrolled, the district/school must contact the
previous district/school attended to request the students’ educational records, including immunization records.
School Currently Attending: ___________________________________________
Reason for leaving current school: _________________________________________________________________
Has the student ever been suspended from school or doe the student have any discipline records? ___Yes ___ No
If yes, please explain: _____________________________________________________________________________
______________________________________________________________________________________________
Educational Program:  Regular Education
 Special Education IEP (example Speech, resource room) ____ YES
If yes, a copy of the IEP must be provided at the time of enrollment.
___ NO
FAMILY INFORMATION
_________________________________________________________________________________________________
Parent/Guardian Last Name
First Name
_________________________________________________________________________________________________
Address (if different from child’s address)
City
ZIP Code
_________________________________________________________________________________________________
Home Phone
Work Phone
Cell Phone
_________________________________________________________________________________________________
E-Mail Address
Are any brothers/sisters currently attending Detroit Service Learning Academy?
If yes, list (LIST ONLY ACTUAL SIBLINGS living in the same household)
□ Yes
SIBLING(S) NAME
CURRENT GRADE
___________________________________________
_______________
___________________________________________
_______________
__________________________________________
_______________
□ No
Are any siblings applying for admissions as NEW applicants to the DSLA for the 2017-2018 school year?
□ Yes
□ No
SIBLING(S) NAME
CURRENT GRADE
___________________________________________
_______________
___________________________________________
_______________
__________________________________________
_______________
Early dismissal sign out: List the nearest relatives or nearest neighbor the school may release student to and contact in case parent/guardian
cannot be reached and emergency pick up is required. Student s will be released only to persons listed below.
Name: ___________________________________Relationship:____________ DaytimePhone: ___________________
Name: ___________________________________Relationship:____________ DaytimePhone: ___________________
Name: ___________________________________Relationship:____________ DaytimePhone: ___________________
Name: ___________________________________Relationship:____________ DaytimePhone: ___________________
I affirm, that as the parent/legal guardian, all information provided above is true and accurate. I also understand
that if I fail to report accurate information, my child may be dismissed from the Detroit Service Learning Academy.