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4515
Campbell Airstrip Road
Anchorage,
AK 99507
Phone:
742-2050 Fax: 742-2060
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| Thank
you for considering Benny Benson Secondary School. We accept students from Bartlett,
Chugiak, Eagle River, and East High Schools. When submitting this application, please include the
studentÕs current transcript and health, attendance, and special education
records. Also provide a
discipline record with details regarding detentions, suspensions, and class
conduct. Please be sure the applicant and parents and guardians understand
the Benson philosophy and work commitment. The student and his or her parents or guardians must
attend an interview prior to enrollment.
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Student
Name__________________________________________ ID Number__________________
Age_______ Birth Date_____________
Grade_______ Credits
Earned_________
Most
Recent School_______________________________________ Currently
Attending?_______
ASD School Zone in Which
Student Lives________________________________________________
Mother/Guardian_______________________________________ Work Phone________________
Father/Guardian________________________________________ Work Phone________________
With Whom Does the Student
Live?_____________________________________________________
Address_____________________________________________________________________________
Home Phone___________________ Mother Cell ______________ Father Cell
________________
Reasons for Referral:
Academics_____
Dropout_____
Legal Issues_____ Probation
OfficerÕs Name_________________________________________
Drugs/Alcohol_____ Current or Past Treatment
Facilities_______________________________
CounselorÕs
Name____________________________________________________________________
Family Issues, Be
Specific______________________________________________________________
_____________________________________________________________________________________
Emotional
Issues______________________________________________________________________
Peer
Problems________________________________________________________________________
Other/Comments_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Special Education:
Has the student ever received
any assistance through special education? Yes____ No____
Is the student being
considered for special education?
Yes____ No____
Does the student have a
current IEP? Yes____ No____ A current 504 Plan? Yes____ No____
Date
of most recent three-year
evaluation_______________________________________________
Academics: List classes in progress and grades to
date
4.___________________________ 5.___________________________ 6.________________________
Vocational/Work Status:
Benson is a academic and
vocational school. All students
must work a minimum of 20 hours per week and/or attend a course at the King
Career Center. There are no exceptions.
Is the student currently
working? Yes____ No____
Current
Employer____________________________________________________________________
Is
the student currently enrolled at and in good standing with KCC? Yes______ No______
What
Class?________________________________________________________________A.M./P.M.
Transportation:
The only transportation to
Benny Benson is a bus to and from King Career Center in the mornings. Otherwise, the student or parent must
provide the studentÕs transportation.
What are the studentÕs transportation
plans?____________________________________________
Name of Referrer (Please
Print) _______________________________________________________
Counselor_______
Administrator_______
______________________________________________________
_______________________
Counselor/Administrator
Signature Date
______________________________________________________
_______________________
Parent Signature Date