Editing previous response:

Please fix the highlighted areas below before submitting.

New Student Enrollment Packet

504 W. Elm Street

Goldsboro, NC 27530

Phone: (919) 581-0128, Fax: (919) 736-3104

Danielle Baptiste	Executive Director	[email protected]
Tasha Adams	K-4 Principal	[email protected]
John Twitty	5-8 Principal	[email protected]

Welcome to Dillard Academy Charter School

Please complete the attached enrollment application package by April 30, 2026

AND

Submit a copy of all required documents by June 30, 2026

(All information must be submitted before the enrollment can be considered complete.)

Required Documents

Certified Birth Certificate

Two Proofs of Residency

(Utility Bill, Housing Documents, Photo ID: Valid North Carolina Photo ID, Government/Tax Documents, or other documents such as bank statement, pay stub, or affidavit of residency (if residing with someone else))

Current Immunization Record - Upcoming Kindergarteners and 7th graders only

NC Health Assessment Transmittal(physical) Form - Kindergarten and new to NC schools students only

See the New Student Enrollment Packet Checklist here

Student Information

Legal Last Name*

Answer required for "Legal Last Name"

Legal First Name*

Answer required for "Legal First Name"

Legal Middle Name*

Answer required for "Legal Middle Name"

Date of Birth*

Answer required for "Date of Birth"

Country of Birth*

Answer required for "Country of Birth"

Street Address*

Answer required for "Street Address"

City*

Answer required for "City"

State*

Answer required for "State"

Zip/Postal*

Answer required for "Zip/Postal"

Social Security Number

Answer required for "Social Security Number"

Contact Phone #*

Number Required

Gender*

Answer required for "Gender"

Male

Female

Ethnicity*

Answer required for "Ethnicity"

Hispanic

Non-Hispanic

Race*

Answer required for "Race"

African American

Asian

American Indian

Hawaiian/Pacific Islander

White

Parent/Guardian Information

Does the student live with both parents? (If YES, list both parents’ information)(If NO list primary parent only)*

Answer required for "Does the student live with both parents? (If YES, list both parents’ information)(If NO list primary parent only)"

Yes

Legal Custody

Answer required for "Legal Custody"

Mother

Father

Stepmother

Stepfather

Grandparent

Foster Parent(s)

Other:

Guardian #1*

Answer required for "Guardian #1"

Mother

Father

Stepmother

Stepfather

Grandparent

Foster Parent

Other:

Full Name*

Answer required for "Full Name"

Street Address*

Answer required for "Street Address"

City*

Answer required for "City"

State*

Answer required for "State"

Zip/Postal*

Answer required for "Zip/Postal"

Employer

Answer required for "Employer"

Position

Answer required for "Position"

Work Phone

Number Required

Cell Phone*

Number Required

Email Address*

Answer required for "Email Address"

Is your mailing address the same as the one listed above? If No, Please provide your mailing address below:

Answer required for "Is your mailing address the same as the one listed above? If No, Please provide your mailing address below:"

Yes

Street Address

Answer required for "Street Address"

City

Answer required for "City"

State

Answer required for "State"

Zip/Postal

Answer required for "Zip/Postal"

Guardian #2

Answer required for "Guardian #2"

Mother

Father

Stepmother

Stepfather

Grandparent

Foster Parent

Other:

Full Name

Answer required for "Full Name"

Street Address

Answer required for "Street Address"

City

Answer required for "City"

State

Answer required for "State"

Zip/Postal

Answer required for "Zip/Postal"

Employer

Answer required for "Employer"

Position

Answer required for "Position"

Work Phone

Number Required

Cell Phone

Number Required

Email address

Answer required for "Email address"

Emergency Contacts

Contact #1 Full Name*

Answer required for "Contact #1 Full Name"

Relationship to Student*

Answer required for "Relationship to Student"

Cell Phone*

Number Required

Home Phone*

Number Required

Work Phone

Number Required

Contact #2 Full Name

Answer required for "Contact #2 Full Name"

Relationship to Student

Answer required for "Relationship to Student"

Cell Phone

Number Required

Home Phone

Number Required

Work Phone

Number Required

Medical Information of Student

Doctor

Answer required for "Doctor"

Phone Number

Number Required

Dentist

Answer required for "Dentist"

Phone Number

Number Required

Allergies of Health Conditions

Answer required for "Allergies of Health Conditions"

Special Needs

Answer required for "Special Needs"

PEP (Personalized Education Plan)

504 (Accommodation Plan)

IEP (Individual Education Plan)

Other:

Military Information, Add if applicable

Full Name

Answer required for "Full Name"

Rank

Answer required for "Rank"

Relationship to Student

Answer required for "Relationship to Student"

Branch of Service

Answer required for "Branch of Service"

Squadron/Unit

Answer required for "Squadron/Unit"

Full Name

Answer required for "Full Name"

Rank

Answer required for "Rank"

Relationship to Student

Answer required for "Relationship to Student"

Branch of Service

Answer required for "Branch of Service"

Squadron/Unit

Answer required for "Squadron/Unit"

Siblings

Full Name of 1st Sibling

Answer required for "Full Name of 1st Sibling"

Grade

Answer required for "Grade"

Full Name of 2nd Sibling

Answer required for "Full Name of 2nd Sibling"

Grade

Answer required for "Grade"

Full Name of 3rd Sibling

Answer required for "Full Name of 3rd Sibling"

Grade

Answer required for "Grade"

Full Name of 4th Sibling

Answer required for "Full Name of 4th Sibling"

Grade

Answer required for "Grade"

Full Name of 5th Sibling

Answer required for "Full Name of 5th Sibling"

Grade

Answer required for "Grade"

Full Name of 6th Sibling

Answer required for "Full Name of 6th Sibling"

Grade

Answer required for "Grade"

Please specify which siblings are ENROLLED in Dillard Academy:

Answer required for "Please specify which siblings are ENROLLED in Dillard Academy:"

1st Sibling

2nd Sibling

3rd Sibling

4th Sibling

5th Sibling

6th Sibling

Other Information

Has this student ever attended another school?

Answer required for "Has this student ever attended another school?"

Yes

If yes, please give the name of the school (s)

Answer required for "If yes, please give the name of the school (s)"

Information Release Form

I (we) have made a voluntary decision to have my (our) child attend Dillard Academy and I (we) give permission for release of all related school records (academic, health, etc.) to the Dillard Academy Charter School.

Do you give permission?*

Answer required for "Do you give permission?"

Yes

Transportation Request Form

(Only for students who require school transportation)

My child will ride the bus to/from home residence listed below: (Check One)

Answer required for "My child will ride the bus to/from home residence listed below: (Check One)"

Both

Pick-Up Address

Answer required for "Pick-Up Address"

City

Answer required for "City"

State

Answer required for "State"

Zip/Postal

Answer required for "Zip/Postal"

Only complete this portion of the form if your child will have an alternate location for pick up or drop off.

My child will ride the bus to/from an alternate location:

Answer required for "My child will ride the bus to/from an alternate location:"

Both

Address

Street Address

Answer required for "Street Address"

City

Answer required for "City"

State

Answer required for "State"

Zip/Postal

Answer required for "Zip/Postal"

Full Name of Person at alternate location

Answer required for "Full Name of Person at alternate location"

Relation to Student

Answer required for "Relation to Student"

Cell Phone

Number Required

LOGO

School Permission Forms

These permission forms are an agreement between Dillard Academy Charter School, Guardian, and the Student indicated below:

Name of Guardian*

Answer required for "Name of Guardian"

Name of Student*

Answer required for "Name of Student"

FIELD TRIP, & PHOTOGRAPH PERMISSION FORM

Click here to read the field trip, & photograph permission form

Do you agree to the Year-Round Field Trip Permission*

Answer required for "Do you agree to the Year-Round Field Trip Permission"

Yes

Do you agree to the Photographic/Video/Web Page Release Authorization*

Answer required for "Do you agree to the Photographic/Video/Web Page Release Authorization"

Yes

Student Acceptable Use & Internet Safety Agreement

Click here to read the Student Acceptable Use & Internet Safety Agreement

Do you agree to follow the Student Acceptable Use & Internet Safety Agreement?*

Answer required for "Do you agree to follow the Student Acceptable Use & Internet Safety Agreement?"

Yes

Parent/School Compact

Click here to read the parent & School Compact

Mobile Device Agreement

Please click here to read the Mobile Device Agreement

Do you agree to the Mobile Device Agreement?*

Answer required for "Do you agree to the Mobile Device Agreement?"

Yes

Do you agree to the parent & school compact?*

Answer required for "Do you agree to the parent & school compact?"

Yes

Parent Custody Notice, if applicable

If parents are legally separated or divorced, by law, each parent has equal rights to the custody of the child or children, unless one parent has obtained a court order indicating otherwise.

Therefore, either parent has the right to inquire as to the daily activities, performance, grades, etc. of his or her child or children. Furthermore, either parent has the right to check the child out of school with proper identification, unless Dillard Academy Charter School has a court order on file.

Provide a copy of the court order to be kept in the student(s) file at Dillard Academy Charter School.

Please indicate below that you have read the above statements.

Name of Guardian #1

Answer required for "Name of Guardian #1"

Have you read the Custody Notice above?

Answer required for "Have you read the Custody Notice above?"

Yes

Date read

Answer required for "Date read"

Name of Guardian #2

Answer required for "Name of Guardian #2"

Have you read the Custody Notice above?

Answer required for "Have you read the Custody Notice above?"

Yes

Date read

Answer required for "Date read"

LOGO

North Carolina Home Language Survey Form

What is the first language the student learned to speak?*

Answer required for "What is the first language the student learned to speak?"

What language does the student speak most often?*

Answer required for "What language does the student speak most often?"

What language is most often spoken in the home?*

Answer required for "What language is most often spoken in the home?"

Country of Birth*

Answer required for "Country of Birth"

If NOT U.S., Date first enrolled in any U.S. school (Private or Public, but not PreK)

Answer required for "If NOT U.S., Date first enrolled in any U.S. school (Private or Public, but not PreK) "

Current School

Answer required for "Current School"

School Enrollment Date

Answer required for "School Enrollment Date"

Current Grade

Answer required for "Current Grade"

LOGO

Mckinney-Vento Homeless Education (ESSA, Every Student Succeeds Acts 2015; Title IX Part A) Questionnaire

Cuestionario de Determinacion de Residencia del Estudiante/Familia

Currently, are you and your family living in any of the situations listed below? Please indicate the situation that describes your present living situation.

Actualmente, usted y su familia viven en alguna de las situaciones enumeradas a continuación? Por favor indique la situación de vida actual.

Unaccompanied Youth (not in the physical custody of guardian) / Joven No Acompañado (No está bajo la custodia física del guardián)*

Answer required for "Unaccompanied Youth (not in the physical custody of guardian) / Joven No Acompañado (No está bajo la custodia física del guardián)"

Yes

Shared Housing (due to loss or hardship) / Compartiendo Vivienda (debido a una pérdida o dificultad)*

Answer required for "Shared Housing (due to loss or hardship) / Compartiendo Vivienda (debido a una pérdida o dificultad)"

Yes

Runaway/homeless youth (even if parents invite the youth home) / Jóvenes fugitivos/sin hogar (incluso si los padres invitan al joven a casa)*

Answer required for "Runaway/homeless youth (even if parents invite the youth home) / Jóvenes fugitivos/sin hogar (incluso si los padres invitan al joven a casa)"

Yes

Lives in hotels, motels, campgrounds / Vive en hotel, motel, o campamento*

Answer required for "Lives in hotels, motels, campgrounds / Vive en hotel, motel, o campamento"

Yes

Lives in shelters (transitional housing shelters for domestic violence) / Vive en refugios (albergues de vivienda transitoria para violencia doméstica)*

Answer required for "Lives in shelters (transitional housing shelters for domestic violence) / Vive en refugios (albergues de vivienda transitoria para violencia doméstica)"

Yes

Lives in cars, parks, public spaces, abandoned buildings, substandard housing / Vive en coche, parques, espacios públicos, edificios abandonados*

Answer required for "Lives in cars, parks, public spaces, abandoned buildings, substandard housing / Vive en coche, parques, espacios públicos, edificios abandonados"

Yes

Campgrounds or inadequate trailer homes / Campamentos o casas rodantes inadecuadas*

Answer required for "Campgrounds or inadequate trailer homes / Campamentos o casas rodantes inadecuadas"

Yes

Abandoned youth in hospital of other place / Jóvenes abandonados en el hospital o otro lugar físico*

Answer required for "Abandoned youth in hospital of other place / Jóvenes abandonados en el hospital o otro lugar físico"

Yes

Migrant camps / Campamentos de migrantes*

Answer required for "Migrant camps / Campamentos de migrantes"

Yes

Unknown nighttime residence / Residencia nocturna desconocida*

Answer required for "Unknown nighttime residence / Residencia nocturna desconocida"

Yes

Currently in foster care awaiting placement or waiting for placement / Actualmente en cuidado de crianza en espera de colocación o en espera de colocación*

Answer required for "Currently in foster care awaiting placement or waiting for placement / Actualmente en cuidado de crianza en espera de colocación o en espera de colocación"

Yes

None of the above applies to my household’s living situation / Ninguna de las anteriores se aplica a la situación de vida de mi hogar*

Answer required for "None of the above applies to my household’s living situation / Ninguna de las anteriores se aplica a la situación de vida de mi hogar"

Yes

If you said "Yes" to any statement, please list the school aged children living with you below. / Si circulo las afirmacione, indique a continuación la información de los niños en edad escolar que están con usted.

Student Name

Answer required for "Student Name"

Age

Answer required for "Age"

Grade

Answer required for "Grade"

School (If not DACS) / Escuela (si no es DACS)

Answer required for "School (If not DACS) / Escuela (si no es DACS)"

Occupational Survey

The Migrant Education Program, through the North Carolina Department of Public Instruction, provides support and instructional services to children and families who have moved in the past three years and who have done agriculture or fishing work. We appreciate your help in determining if your children or relatives qualify to receive services in this program. Please answer the following questions and return the survey to the school.

Have you or someone in your family worked in any of the following areas below in the last three years?*

Answer required for "Have you or someone in your family worked in any of the following areas below in the last three years?"

Yes

Select all that apply*

Answer required for "Select all that apply"

Work in the harvest of fruits and vegetables, tobacco, sweet potatoes, nuts, cotton, or in agricultural farms, ranches, fields, and vineyards

Working in a fruit or vegetable cannery or in a fruit or vegetable packing plant

Working in a dairy

Working in a fishery or on a shrimp or catfish farm

Working in a slaughter house (chicken, cow, or pig)

Working on a poultry or hog farm

Working in a plant nursery or orchard; growing or harvesting trees

Other: Please indicate similar work in agriculture

Other:

How long ago did you arrive to this country? (Month & Year, since birth)*

Answer required for "How long ago did you arrive to this country? (Month & Year, since birth)"

Have you or your family moved to another school district or to another city or county in the last three years? *

Answer required for "Have you or your family moved to another school district or to another city or county in the last three years? "

Yes

LOGO

Parent Medication Information Letter

Please click here to read the parent medication information letter.

Please click here to download and print the AUTHORIZATION FOR MEDICATION TO BE GIVEN DURING REGULAR HOURS form. FORMS MUST BE SIGNED BY A PHYSICIAN. and returned to the school. If you don't have a printer, forms are available at the school.

School Health Information Letter

Please click here to read the school health information letter.

Required Documents Information

BIRTH CERTIFICATE

HEALTH ASSESSMENT + IMMUNIZATIONS

2 PROOFS OF ADDRESS

Verification of the address must be accompanied by two or more of the items from the list shown below. Please be sure that the documents that you provide have a physical address. No documents with only post office box information will be accepted.

Select Documents*

Answer required for "Select Documents"

Governmental Benefits Lettr

Bank Statement

Cable/Internet Bill

Current Utility Bill

Current Driver’s License

Lease Agreement

Medicaid Card

Military ID Card

Mortgage Documents

Deed to Property

Motor Vehicle Insurance Card

Motor Vehicle Registration

Payroll/W-2 Stub

Phone Bill

Property/Tax Records

REAL ID

Voter Registration Card

U.S. Passport

If "Other" Specify. (Requires Operations Director Approval)

Answer required for "If \"Other\" Specify. (Requires Operations Director Approval)"

NC Health Assessment & Immunizations Requirement

North Carolina law requires Health Assessments, including physical examinations, and updated immunizations for all children starting kindergarten each year. The Health assessment must be completed within 12 months prior to the first day of kindergarten.

A blank form is attached here. If your child has not had a physical examination since August 20, 2025, make sure to call your child’s doctor or the North Carolina State Health Department for an appointment.

Kindergarten and 7th Grade Only

Kindergarten

Information Release Form

Upload any required documents here, or bring them to the school

Answer required for "Upload any required documents here, or bring them to the school"

Choose a file or drag it here.

Print Name of Legal Guardian*

Answer required for "Print Name of Legal Guardian"

Print Full Name of Student*

Answer required for "Print Full Name of Student"

Signature*

Signature Required

Name: Date:

Sign this form

By pressing “Sign Form,” you are agreeing to signing this form electronically.

Signature *

Type to sign

Draw your signature

Full Name *

Date:

Confirmation Email

Confirmation Email *

Answer required for "Confirmation Email"

Submitting form...

Protected by reCAPTCHA - Privacy - Terms

Please verify you are not a robot:

Please fix errors above