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STUDENT INFORMATION
Full name

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Date of birth

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Gender

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Address

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Apt #:
City

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State:

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Zip:

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Telephone:

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Current School Name & Address, if any:
Current grade:
New York City Public School ID number:
Grade Student will enter in August 2010:
Note: Student must be 5 years old by December 31, 2010 to be eligible for Kindergarten - 2nd grade.

PARENT/GUARDIAN INFORMATION
Name

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Home phone:

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Relationship:

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Cell phone:
Work telephone:
Address:

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Apt #:
Zip:

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Email:

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Language spoken with child at home:

SECOND PARENT/GUARDIAN INFORMATION
Name
Home phone:
Relationship:
Cell phone:
Work telephone:
Zip:
Apt #:
Address:
Email:
Language spoken with child at home:

Brothers and sisters have preference in the admissions lottery, but only if an application is submitted for each one.
Name of sibling:
Grade:
Name of sibling:
Grade:

This application will not be valid if it contains incorrect information.
This is an equal opportunity, free public charter school, open to all children. It is necessary for new applicants to apply each year. Currently enrolled students need not re-apply.

For information, please call: 765 430 5850.
Parent/Guardian Signature:

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(type in your full name to sign)
Date:

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enter the four black letters you see (not the gray ones):


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