Application

Please complete ONE application for each child in the family if more than one. (Martin County students will only be considered for enrollment in Mosaic Digital Academy if found eligible).

All applicants must provide:

Proof of address (Parent/Guardian’s name and address must be showing on the proof of address.Not acceptable: driver’s license, voter’s registration card, or cable bill)

ONE of the following documents is required as Proof of address:

Current utility bill – within the last 30 days
Official rent receipt
Current mortgage deed
Signed lease agreement
Mortgage payment coupon
Builder’s Contract (6 month completion)
Affidavit of Residence

If the student is a kindergartner, you MUST provide:

Original Birth Certificate
Immunization Records (Schedules http://www.cdc.gov/vaccines/schedules/)

If the student is a 7th grader, you MUST provide:

Immunization Records (Schedules http://www.cdc.gov/vaccines/schedules/)

If the student is new to the district/state, you MUST provide:

Original Birth Certificate
Immunization Records (Schedules http://www.cdc.gov/vaccines/schedules/)
Previous Academic Records (report card, transcript, etc.)
Home Language Survey (complete this if new to public school)

I. STUDENT PROFILE

Student First Name

Student Middle Name

Student Last Name

ID# (56 number)

Grade Level (upcoming fall semester)

Birth Date

Sex

Male

Female

Race

American Indian/Alaskan Native

Asian

Black

Hawaiian/Pacific Islander

White

Ethnicity

Hispanic/Latino

Not Hispanic/Latino

Race:

American Indian or Alaska Native. A person having origins in any of the originals peoples of North and South America (including Central America) and who maintains tribal affiliation or community attachment.
Asian. A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, e.g., Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
Black or African American. A person having origins in any of the black racial groups of Africa.
Native Hawaiian or Other Pacific Islander. A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
White. A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

Ethnicity:

Hispanic or Latino. A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.
Not Hispanic or Latino.

Place of Birth ( City, State, and Country)

Primary Language Spoken at Home

Social Security Number

Student social security numbers are collected in order to identify students within the District’s computer system and will be used only for that purpose.)

Previous School (Name, City, and State)

In which county do you reside?

St. Lucie

Martin

Okeechobee

Palm Beach

Home Address

City and Zip Code

Mailing Address (if different)

City and Zip Code

Home Phone

Work Phone

Emergency Phone

II. GUARDIAN INFORMATION: Residential/Custodial Parent

Primary Email Contact

Father

Mother

Other

Parent/Guardian Last Name

First and Middle Names

Birth Date

Father

Mother

Other

Parent/Guardian Last Name

First and Middle Names

Birth Date

III. PREVIOUS PROGRAM INFORMATION

Has your child been participating in an exceptional education program?

Yes

Exceptional Education Program

Other Health Impaired

Orthopedically Impaired

Traumatic Brain Injury

Visually Impaired

Deaf or Hard of Hearing

Autism Spectrum Disorder

Hospital/Homebound

Intellectually Disabled

Specific Learning Disability

Developmentally Delayed

Emotionally/Behaviorally Disabled

Speech Impaired

Dual Sensory Impaired

Language Impaired

Indicate if any apply to your child:

Expulsions

Date

Arrests

Date

Juvenile Justice Actions

Date

IV. DIVERSITY INFORMATION

Has the student (or sibling in the same household) received free or reduced-price meals at school in St. Lucie County in the last year?

Yes

Do you receive Food Stamps or TANF for the student (or sibling in the same household)?

Yes

Is the student (or sibling in the same household) eligible for Medicaid?

Yes

Does the student (or sibling in the same household) receive benefits from the Women, Infants and Children (WIC) program?

Yes

Does your child have an active 504 Plan?

Yes

V. SIBLINGS

Please list all siblings. Of the siblings listed, please check which are currently attending or applying for your first choice school.

Siblings are defined as brother, sister, half-brother, half-sister, stepbrother or stepsister living in the same household.

Does the child have siblings?

Yes

Sibling Last Name

First and Middle

Race

American Indian/Alaskan Native

Asian

Black

Hawaiian/Pacific Islander

White

Birth Date

Ethnicity

Hispanic/Latino

Not Hispanic/Latino

Sex

Male

Female

Sibling Last Name

First and Middle

Race

American Indian/Alaskan Native

Asian

Black

Hawaiian/Pacific Islander

White

Birth Date

Ethnicity

Hispanic/Latino

Not Hispanic/Latino

Sex

Male

Female

Sibling Last Name

First and Middle

Race

American Indian/Alaskan Native

Asian

Black

Hawaiian/Pacific Islander

White

Birth Date

Sex

Male

Female

Ethnicity

Hispanic/Latino

Not Hispanic/Latino

VI. EQUIPMENT INFORMATION

Do you have a computer at home?

Yes

Make

Operating System

Do you have internet access at home?

Yes

Service Provider

VII. MEDICAL INFORMATION

My Child’s Doctor

Medicaid

Yes

Number

Insurance Provider

Number

Allergies to Medications

Yes

Specify Medication Name(s)

Allergic Reaction to bee stings, ant bites, food

Yes

Specify

Can you provide medical documentation of the above?

Yes

Pollen and Other Allergies

Yes

Specify allergy and medications

AGREEMENTS AND CONSENT

I understand that in case of emergency if my child is at a school site my child will be taken to a hospital and given the necessary treatment.
I understand that I am to pay the bill, including emergency transport.
I understand that certain educational records of my child will be shared with the district Health Care Partners as needed to provide and evaluate health services to students.
I also understand and agree that my child’s medical treatment records created by health care personnel at school may be shared with school officials who have a Legitimate Educational Purpose for accessing such treatment records.
I also consent that the school district and their health partners are able to bill Medicaid for any services for which my child is eligible.

The Parent/Guardian must acknowledge this agreement.

I Agree

If an application is completed for a currently enrolled student, the current seat will no longer be available.

I have read and understand the directions for applying for my child’s assignment.
I agree to abide by the policies of St. Lucie County Public Schools.
I testify that all of the information on this form and the documentation submitted with my request are true and accurate.
I understand that failure to comply with these conditions, or falsification of any portion of this application may result in the revocation of my assignment.

The Parent/Guardian must acknowledge this agreement.

I Agree

UPLOAD REQUIRED DOCUMENTATION

Please upload proof of address, and any other documentation that is required for your child.*

Proof of Residency and up to date Immunizations are required for processing this application.

Out of county and/or state applicants must provide transcripts and/or report cards for Middle and High School placement.

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