Enrollment (waitlist only)

Independence Charter Academy provides the premier alternative educational environment in California. Enroll your student today to begin your child’s journey to excellence through a tailored education plan created with their best interests and learning style in mind. Our culture of excellence aligned with our passionate teachers and staff work creates a unique educational environment for students to achieve real-world success.

To get started, please provide some basic information about yourself and your student.

If you’d prefer to complete a paper copy of this enrollment packet and fax it, you may download a copy here.

All of our students have unlimited access to our online portals, education resources and valuable affiliations with many of the top universities in California. Enroll today!

Step 1 of 6

Family Information
Primary Caregiver(s) - Lives with Student
Only Natural Parent(s) and Legal Guardian(s) having legal custody shall act as Custodial Parents. All others must have Authorization from Natural Parent(s) to act as Custodial Parent.
Primary Caregiver #1*
First Last
Relationship to Student*
Email*
Cell Phone Number*
Work Phone Number
Highest Level of Education
Military
- Active Duty
- Retired
Occupation
Place of Employment
Primary Caregiver #2
First Last
Relationship to Student
Email
Cell Phone Number
Work Phone Number
Highest Level of Education
Military
- Active Duty
- Retired
Occupation
Place of Employment
Natural Parent (Not Living With Student)
Name
First Last
Relationship to Student
Email
Address
Street Address City State / Province / Region ZIP / Postal Code
Home Phone Number
Cell Phone Number
Work Phone Number
Occupation
Place of Employment
Send Mail?
- Yes
- No
Siblings
Use the plus button to add more.

Name	Date of Birth	Relationship to Student	Lives at Home?

Emergency Contacts
Use the plus button to add more.

Name	Relationship to Student	Lives with Student?	Home #	Work #	Cell #

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Authorization to Consent to Treatment of Minor
(I/We), the undersigned, parent(s) of the student, a minor, do hereby authorize the Helendale School District or its designee as agent for the undersigned to consent to any X-ray examination, anesthetic, medical, dental, or surgical diagnosis or treatment and hospital care which is deemed advisable by, and is rendered under the general or special supervision of any physician and surgeon licensed under the provisions of the Medicine Practice Act or any dentist licensed under the Dental Practice Act, whether such diagnosis or treatment is rendered at the office of a physician, dentist or at a hospital. We further authorize the hiring of an ambulance or other emergency vehicle to transport, at my/our expense, such minors to a suitable place where medical or dental care is provided. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required but is being given to provide authority and power on the part of the aforesaid agent to give specific consent to any and all such diagnosis, treatment, or hospital care which a physician or dentist in the exercise of his best judgment may deem advisable. This authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of California, and after a reasonable attempt has been made to contact the parent(s). This authorization shall remain effective until revoked in writing and delivered to said agent.
Electronic Signature of Parent*
Today's Date*
MM slash DD slash YYYY
Student/Parent Handbook
Student/Parent Handbook*
We have read and understand the Independence Charter Academy Parent/Student Handbook. We will abide by all rules and responsibilities. Printed copies available by request.
- I have read the ICA Student Handbook
Electronic Signature of Student*
Electronic Signature of Parent*

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Helendale School District Request for Student Records
We have read and understand the Independence Charter Academy Parent/Student Handbook. We will abide by all rules and responsibilities. Printed copies available by request.
Public law 93-380 (The Family Education Rights and Privacy Act of 1974) states in part that when student records are to be transferred to another school, and/or agency, parents or guardians of students, or students over 18 years of age, be notified of such transfer, receive a copy of the records being transferred if desired, and have an opportunity for a hearing to challenge the content of the record.

In order to honor the request for transfer of records, approval is necessary as indicated below. Copies of such records may be obtained by parents or guardians of students, or students over 18 years of age, by submitting a request in writing to the school office (there may be a charge not to exceed $0.25 per page copied in order to defray costs).

Request transfer of:
- Medical and Health Records
- Cumulative Folder and Transcript
- Any Psychological Testing and Special Education Placements
Previous School Attended*
School Address*
Street Address City State / Province / Region ZIP / Postal Code
School Email Address*
School Fax Number*
Name of Student*
Date of Birth*
MM slash DD slash YYYY
Electronic Signature of Parent or Authorized School Employee*
Today's Date*
MM slash DD slash YYYY
Authorization for Student Records*
I understand by submitting this form, I am giving permission to Independence Charter Academy to secure the student records for the student listed above. My electronic signature above serves as my signature of approval.
- I consent
Final Information
How did you hear about Independence Charter Academy?*
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.

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Enrollment (waitlist only)

Step 1 of 6

Student Information

School Information

Special Programs

Family Information

Primary Caregiver(s) - Lives with Student

Natural Parent (Not Living With Student)

Siblings

Emergency Contacts

Medical Information

Language Survey

Authorization to Consent to Treatment of Minor

Student/Parent Handbook

Helendale School District Request for Student Records

Final Information