Alternative Programs and Support Application

About You

First Name

Last Name

Email Address

Current Date*

INDEPENDENT STUDY 9-12

HOME HOSPITAL

EL CAMINO

INDEPENDENT STUDY K-8

Student First Name*

Student Last Name*

Student ID Number

Grade*

Student Email Address*

Age*

Date of Birth*

Student Cell Number

Street Address*

City*

Zip Code*

School of Residence*

School Currently Attending*

Parent or Guardian First Name*

Parent or Guardian Last Name*

Parent or Guardian Email Address*

Home Phone Number

Parent or Guardian Work Number*

Parent or Guardian Cell Number*

Reason for Alternative Placement Request*

Anticipated Duration of Alternative Education Enrollment*