NEW YORK CITY COMMON CHARTER SCHOOL APPLICATION2010-2011

Name of Charter School:_______________________________________________________________School address:______________________________________________________________________

Deadline:

Common applications must be delivered to the school by hand, mail, or email no later than

April1

, 2010.

Please contact the school directly to see if any additional information is required prior to thedeadline.

Student Information

Student’s Last Name

:___________________ First Name:_________________ Middle Initial:__Date of Birth:__-__-____ N.Y.C. Student I.D.: _________________ Circle One: (Male/Female)Entering Grade for fall 2010:_____________ Current School:________________________Community School District where student resides:______________________________

Student Information

Student’s Last Name:_________________________________________________________________

First Name:___________________________________________________________ Middle Initial:__Date of Birth:__-__-____ Student I.D.: _________________ Circle One: (Male/Female)Address:_______________________________________________, City:_______________________State:____________ Zip:_______________, Entering Grade for fall 2010:_______________________Current School:______________________________________________________________________Community School District where student resides (NYC residents only):_________________________(Check your Community School District by calling the number 311 or online by entering your address at:(http://gis.nyc.gov/dcp/at/f1.jsp)

Parent/Guardian Information

Last Name:__________________________________________________________________________First Name:________________________________________________________ Middle Initial______Primary Phone: (___)____________ Work Phone:(___)__________ Cell Phone:(___)_________Email:________________________________Last Name:___________________________________________________________________________First Name:________________________________________________________ Middle Initial_______Primary Phone: (___)____________ Work Phone:(___)__________ Cell Phone:(___)_______________Email:_________________________________

Siblings

Does the applying student have a sibling attending this charter school? Circle one: (

YES/NO

)If so, please list name, grade and date of birth of sibling:

1) Last Name:___________________________________________, Grade:_____________________First Name:__________________________________________________, Date of Birth:___/___/_________2) Last Name:___________________________________________, Grade:_____________________First Name:__________________________________________________, Date of Birth:___/___/_________

Agreement

I affirm that the information I have submitted above is true to the best of my knowledge. Additionally, I understand that submittingthis application does not guarantee admission to the charter school mentioned above.Print Name:____________________________________Signature:______________________________________ Date (month/day/year): __/__/____

At-Risk Categories:

This information is optional but providing it may increase your student’s chances of admission

tocertain schools. Please contact each school that you are interested in before April 1, 2010 to see what, if any, at-risk criteria the school may have and provide such information in the space below. You may also have to providesupporting documentation, if required by the school.____________________________________________________________________________________________