YEAR 2014-2015
Date_________________________
STUDENT/PARENT INFORMATION SHEET
Last Name________________________First Name_____________________Middle Name________________
***Name as it appears on Birth Certificate***
Home Physical Address_______________________________________________________________________
Mailing Address(if different from above)__________________________________________________________
Home Telephone #________________ Student Cell #________________DOB___________Grade_________Sex______
Ethnicity: (Please circle one) Asian African/American African American/American Indian Hispanic Other
American Indian
Hawaiian/Pacific Islander White White/Asian White/African American White/American Indian
Social Security #________________________ Place of Birth____________________________
Has this student ever attended school in Horry County? Yes___________No_________
If yes, what was the name of the school__________________________________________________
NEW TO HORRY COUNTY SCHOOLS – Parents are responsible for providing/obtaining student educational records
from any previous school district. Name and address of the last school attended:
Name/Address of Last school attended:____________________________________________________________
Father’s Name____________________________________Work #___________________Cell #__________________
Mother’s Name___________________________________Work#____________________Cell#__________________
Guardian’s Name__________________________________Work#___________________Cell#__________________
Father’s Address_________________________________________________________________________________
Mother’s Address________________________________________________________________________________
Guardian’s Address_______________________________________________________________________________
Home#_________________________________________________________________________________________
Home e-mail____________________________________________________________________________________
Student lives with: Both Parents________Mother______Father_____Stepmother______
Stepfather________Legal Guardian________ Foster Mother_______Foster Father_____
(Must provide court documentation at enrollment) NOTE: Parents are responsible for alerting school staff to any
court documentation that impacts custodial rights, educational rights to student records, visitation, etc. Copies of
these documents must be provided to the school.
STUDENT/PARENT INFORMATION SHEET Cont:
Does this student have an IEP? NO___________YES________
Does this Student have a 504 Plan? NO________YES__________
Does this student have a Behavioral Plan? NO________YES________
Does this student have any pending litigation/criminal charges? If so, what is the nature of these charges
______________________________________________________________________________________.
Has this student attended Horry County Alternative School or Department of Juvenile Justice?
No_____Yes______
If so, for what reason____________________________________________________________________.
By submitting this application:
 I understand that the school philosophy requires parental and student involvement and I agree to be an
active participant in my child’s (children’s) education.
 I understand I am responsible for updating the school with any changes in contact information I have
provided in this application.
PARENT/GUARDIAN SIGNATURE_______________________________________Date_________________
Palmetto Academy for Learning motorsports is committed to the principle of equal opportunity in education and employment PALM does not
discriminate against individuals on the basis of race, color, religion, sex, national origin, ethnic origin, marital status, disability or age.
Student can begin classes at Palmetto Academy for Learning Motorsports within 72 hours of registration. This will allow for obtaining
transcripts, scheduling orientation and obtaining of any other information needed prior to attendance.