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Returning Student Enrollment Form

DACS Logo

504 W. Elm Street

Goldsboro, NC 27530

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

Danielle Baptiste	Executive Director	[email protected]
Tasha Adams	Lower School Principal	[email protected]
John Twitty	Upper School 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 the following enclosed documents by June 30, 2026

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

Enrollment Documents

Current Imunization Records - 7th Graders Only

NC Health Assessment Transmittal (physical) Form - if any changes in medical condition

See the New Student Enrollment Packet Checklist here

Student Information Form

Legal First Name*

Answer required for "Legal First Name"

Legal Last Name*

Answer required for "Legal Last Name"

Legal Middle Name

Answer required for "Legal Middle Name"

Date of Birth*

Answer required for "Date of Birth"

Address*

Answer required for "Address"

City*

Answer required for "City"

State

Answer required for "State"

Zip/Postal

Answer required for "Zip/Postal"

Phone Number

Answer required for "Phone Number"

Parent/Guardian Information (ONLY IF any changes/updates)

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(s)

Other

Name

Answer required for "Name"

Address

Answer required for "Address"

City

Answer required for "City"

Address

State

Answer required for "State"

Zip/Postal

Answer required for "Zip/Postal"

Employer

Answer required for "Employer"

Position

Answer required for "Position"

Work Phone

Answer required for "Work Phone"

Cell Phone

Answer required for "Cell Phone"

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(s)

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

Answer required for "Work Phone"

Cell Phone

Answer required for "Cell Phone"

Email Address

Answer required for "Email Address"

Emergency Contacts (If any changes/updates)

Contact #1 Full Name

Answer required for "Contact #1 Full Name"

Relationship to Student

Answer required for "Relationship to Student"

Home Phone Number

Answer required for "Home Phone Number"

Work Phone Number

Answer required for "Work Phone Number"

Cell Phone Number

Answer required for "Cell Phone Number"

Contact #2 Full Name

Answer required for "Contact #2 Full Name"

Relationship to Student

Answer required for "Relationship to Student"

Home Phone Number

Answer required for "Home Phone Number"

Work Phone Number

Answer required for "Work Phone Number"

Cell Phone Number

Answer required for "Cell Phone Number"

Medical Information (If any changes/updates)

Doctor

Answer required for "Doctor"

Phone Number

Answer required for "Phone Number"

Dentist

Answer required for "Dentist"

Phone Number

Answer required for "Phone Number"

Allergies or Health Conditions

Answer required for "Allergies or Health Conditions"

Medications

Answer required for "Medications"

Special Needs

Answer required for "Special Needs"

IEP (Individualized Education Plan)

PEP (Personalized Education Plan)

504 (Accommodation Plan)

Other:

Transportation Request Form

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)"

A.M

P.M

Both

Home Address

Answer required for "Home 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 alternative location:

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

A.M

P.M

Both

Street Address

Answer required for "Street Address"

City

Answer required for "City"

State

Answer required for "State"

Zip/Postal

Answer required for "Zip/Postal"

Name of the Person at Alternative location

Answer required for "Name of the Person at Alternative location"

Relation to Student

Answer required for "Relation to Student"

Cell Phone

Answer required for "Cell Phone"

LOGO

School Permission Forms

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

Name of the Guardian*

Answer required for "Name of the Guardian"

Name of the Student*

Answer required for "Name of the Student"

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

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

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

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

Yes

Click here to read the Parent & School Compact Agreement

Do you agree to the Parent & School Compact Agreement?*

Answer required for "Do you agree to the Parent & School Compact Agreement?"

Yes

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

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 the 1st Guardian

Answer required for "Name of the 1st Guardian"

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 the 2nd Guardian

Answer required for "Name of the 2nd Guardian"

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"

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(s)

Answer required for "Student Name(s)"

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)"

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 to be completed by the physician and returned to the school. If you don't have a printer, forms are available at the school.

Required Documents Information

Physician Signed Physical Forms - (If any changes in medical condition, we should be made aware)

Signed Physician Athletic Physical Forms - (For middle school athletics)

Click here for a printable copy of the athletic physical form, or pick the form up at the school

Immunizations - (7th Graders Only)

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.

7th Grade Only

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"

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