Instant Impact Global Prep Student Registration for the 23-24 School Year Instant Impact Global Prep Student Registration for the 23-24 School Year Welcome to Instant Impact Global Prep Charter School The following documents are required when registering a child to attend Instant Impact Global Prep (IIGP) School. _____Social Security Card _____Photo ID (Drivers license, state ID, or Passport) _____Two Proofs of Residency (Ex. utility bill, property tax bill, lease agreement, and etc...) ______Birth Certificate or Passport (Supported file type: jpg, jpeg, jpe, png, gif, docx, pdf) _____ Child's Immunization Record _____Child's Most Recent Report Card (not required for Kindergarten) _____ Signature of parent (Supported file type: jpg, jpeg, jpe, png, gif) School Information School Name School Code School Year Today's Date Student Information Name Name Name Name Name Entering Grade Level Gender Male Female Social Security Number Address Address Address Address Address Address State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Address Phone Unlisted No Yes Is student Hispanic or Latino? Yes No Race/Ethnic Code Black/African-American White/Caucasian Asian American Indian/Alaskan Native Native Hawaiian/Other Pacific Islander (Must check all that apply.) Student's Birthplace (City): Student's Birthplace (State): Student's Birthplace (Country) AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaCountryVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweCountry Student's Birthdate Birth Document Source (birth certificate, passport, etc.; provide document) Nationality Date student was enrolled in U. S. schools: Has student ever received English as a Second Language (ESL) or Bilingual services? Yes No Is student a Foreign Exchange student? Yes No If Yes, enter 1-94 number: Instant Impact Global Prep Schools is required to identify students whose parent is (or parents are) in the U.S. Armed Forces (Active Duty or Reserve status) or in the National Guard. Parent/Guardian in U.S. Military or National Guard? No Yes Parent's/Guardian's Name: Parent or Gurdian Parent Gurdian Parent's/Guardian's Resident School District Enrollment Reasons (Check One) From out of state / out of country From home school in MS From nonpublic school in MS From an MS public district or charter (community) school First time in MS public school due to age Emergency Contacts Name Relationship to Student Phone Cell Phone Primary Care Doctor & Phone Language A completed language usage survey is required for all students upon enrollment in Mississippi schools. This information will tell school staff if they need to check your child's proficiency in English. Answers to these questions ensure your child receives the education services to succeed in school. The information is not used to identify immigration status. Communication Preferences Indicate your language preference so we can provide an interpreter or translated documents at no cost when you need them. All parents have the right to information about their child's education in a language they understand. In what language(s) would your family prefer to communicate with the school? Language Background Information about your child's language background helps us identify students who qualify for support to develop the language skills necessary for success in school. Testing may be necessary to determine if language supports are needed. What language does this student speak most frequently? (Primary language) What language is most often spoken by adults at home? (Home language) What was this student's first language? (First language) Prior Education List student's previous schools, beginning with most recent school, including preschool: School Name-1 Address (School-1) Address (School-1) Address (School-1) Address (School-1) Address (School-1) Address (School-1) Address (School-1) Address (School-1) Country (Sch-1) Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Grades (School-1) Date from (Sch-1) Date to (Sch-1) School Name-2 Address (School-2) Address (School-2) Address (School-2) Address (School-2) Address (School-2) Address (School-2) Address (School-2) Address (School-2) Country (Sch-2) Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Grades (School-2) Date from (Sch-1) Date to (Sch-2) Preschool Experience (Check all that apply.) At a preschool / Head Start program At a Head Start program At a full-day, full-year childcare center At a part-time private preschool At a family childcare home At home OtherOther Kindergarten Experience Half day All Day Siblings Name (Sibling-1) Name (Sibling-1) Name (Sibling-1) Name (Sibling-1) Name (Sibling-1) Gender (Sibling-1) Male Female School Attending (Sibling-1) Grade (Sibling-1) Age (Sibling-1) Name (Sibling-2) Name (Sibling-2) Name (Sibling-2) Name (Sibling-2) Name (Sibling-2) Gender (Sibling-2) Male Female School Attending (Sibling-2) Grade (Sibling-2) Age (Sibling-2) Name (Sibling-3) Name (Sibling-3) Name (Sibling-3) Name (Sibling-3) Name (Sibling-3) Gender (Sibling-3) Male Female School Attending (Sibling-3) Grade (Sibling-3) Age (Sibling-3) Parent Information Parent Mother Father Guardian Stepparent Foster parent Grandparent Surrogate parent OtherOther Name Name Name Name Marital Status Married Unmarried Widowed Separated Divorced If you check Separated or Divorced, we require current legal documentation related to the children. Deceased? No Yes District of Residence District of Primary Residence Resides with Student? No Yes Address Address Address Address Address Address State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Address Phone Unlisted? No Yes Cell Phone Email Address Employer Work Address Work Phone Custodial Parent? No Yes Legal Guardian? No Yes Grandparent POA? No Yes Caregiver Authorization? No Yes Migrant Worker? No Yes Receive School Mail (if not Custodial Parent)? No Yes Parent-2/ P-2 Mother Father Guardian Stepparent Foster parent Grandparent Surrogate parent OtherOther Name (P-2) Name (P-2) Name (P-2) Name (P-2) Marital Status (P-2) Married Unmarried Widowed Separated Divorced If you check Separated or Divorced, we require current legal documentation related to the children. Deceased? (P-2) No Yes District of Residence (P-2) District of Primary Residence (P-2) Resides with Student? (P-2) No Yes Address (P-2) Address (P-2) Address (P-2) Address (P-2) Address (P-2) Address (P-2) State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Address (P-2) Phone (P-2) Unlisted? (P-2) No Yes Cell Phone (P-2) Email Address (P-2) Employer (P-2) Work Address (P-2) Work Phone (P-2) Custodial Parent? (P-2) No Yes Legal Guardian? (P-2) No Yes Grandparent POA? (P-2) No Yes Caregiver Authorization? (P-2) No Yes Migrant Worker? (P-2) No Yes Receive School Mail (if not Custodial Parent)? (P-2) No Yes Students With Special Needs Does child require mobility assistance? i.e. wheelchair, etc.) No Yes Did child receive Special Education and related services in most recent school? No Yes Does this child have a current IEP (Individualized Education Program)? No Yes Does child have a 504 Accommodation Plan? No Yes Did child receive Gifted services in most recent school? No Yes Temporary Living Arrangements Answers to these questions will help determine what services the student may be eligible to receive. Is student's current address a temporary living arrangement? No Yes No Is this temporary living arrangement due to loss of housing or economic hardship? No Yes If answer to both of these questions is Yes, the student is entitled to immediate enrollment. Where is the student living now? In a motel or hotel Doubled up with family or friend In a homeless shelter Unaccompanied youth Other (a place not designed for ordinary sleeping accommodations)Other (a place not designed for ordinary sleeping accommodations) How Did You Hear About Instant Impact Global Prep School? IIGP Publication IIGP Website Friend or Relative Billboards Letter or Postcard Television News Story IIGP Staff Member Radio Printed Advertisement Newspaper Story IIGP Event OtherOther Understanding Statement I understand that any inaccurate information provided about this student on any page of this Student Registration Information Form may result in a change of grade level, a change of class, or an immediate transfer or withdrawal from this school. Signature Drop your signature here or click to upload Choose File Maximum upload size: 5MB Supported file type: jpg, jpeg, jpe, png, gif Date of signature Request to Restrict Privacy Information Federal and MS laws prohibit Instant Impact Global Prep School (IIGP) from publicly releasing information about our students, except for designated "Directory Information." Per Board Policy No. 8330, IIGP defines Directory Information as the following: A student's name, school, grade level, parent-guardian's name, home address, telephone number, email address, participation in officially recognized activities and sports, and awards received Under MS public records law, IIGP is required upon request to provide the above Directory Information to any member of the public who requests it. IIGP' primary purpose for releasing Directory Information is to highlight students' accomplishments. Parents, legal guardians, or students age 18 or over may refuse to allow CPS to release Directory Information. Please indicate if you wish to restrict IIGP from releasing Directory Information on the student named below by checking the appropriate box and returning this form to your child's school. Authorization I Name of Parent Name of Parent/ Guardian or Student 18 years old authorize the release of records pertaining to Student's Name Student's Name Student's Name Student's Name Student's Name Student's Birthdate From the following school or institution: Most Recent School Address of School or Institution Address of School or Institution Address of School or Institution Address of School or Institution Address of School or Institution Address of School or Institution State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Address of School or Institution Telephone No. Fax No. Grade Level The following records* should be released: Transcript of subjects and grades Attendance Record Psychological or Other Individual Test Results 504 Accommodation Plan English Language Proficiency Assessments Special Education Records, including IEP, MFE or ETR, and behavior plan MS Achievement and Graduation Test Results Standardized Test Results Gifted Assessments Health Records * Records that cannot be withheld due to non-payment of fees or obligations: State test scores, Individualized Educational Program (IEP), IEP progress reports, Multifactored Evaluation (MFE) or Education Team Report (ETR), and immunization records. Release records to: New School Address of New School Address of New School Address of New School Address of New School Address of New School Address of New School State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Address of New School Telephone No. (New School) Fax No. (New School) I am authorizing the release of these records because (Check one): I am the parent, guardian or custodian of the subject of these records, and the subject is under 18 years. I am the parent, guardian or custodian of the subject of these records, and the subject is under 18 years. I am the subject of these records, and I'm 18 years of age or older. I am the subject of these records, and I'm 18 years of age or older. Signature Drop your signature here or click to upload Choose File Maximum upload size: 5MB Supported file type: jpg, jpeg, jpe, png, gif Date of signature Documents Upload Birth Certificate or Passport Drop the birth certificate or passport here or click to upload Choose File Maximum upload size: 15MB Supported file type: jpg, jpeg, jpe, png, gif, docx, pdf Social Security Card Drop the social security card here or click to upload Choose File Maximum upload size: 15MB Supported file type: jpg, jpeg, jpe, png, gif, docx, pdf Photo ID Drop the Photo ID here or click to upload Choose File Maximum upload size: 15MB Supported file type: jpg, jpeg, jpe, png, gif, docx, pdf Child's Immunization Record Drop the child's immunization record here or click to upload Choose File Maximum upload size: 15MB Supported file type: jpg, jpeg, jpe, png, gif, docx, pdf Child's Most Recent Report Card Drop the child's most recent report card here or click to upload Choose File Maximum upload size: 15MB Supported file type: jpg, jpeg, jpe, png, gif, docx, pdf Proofs of Residency. Drop the proofs of residency here or click to upload Choose File Maximum upload size: 15MB Supported file type: jpg, jpeg, jpe, png, gif, docx, pdf If you are human, leave this field blank. Submit Δ