NORWALK PUBLIC SCHOOLS CHOICE SCHOOLS

LOTTERY APPLICATION

COLUMBUS MAGNET SCHOOL

JEFFERSON SCIENCE MAGNET SCHOOL
SILVERMINE ELEMENTARY – SPANISH/ENGLISH DUAL LANGUAGE IMMERSION PROGRAM
(PLEASE PRINT CLEARLY)

Child’s Name____________________________________________ Birth Date______________ Gender: M F

Parent/Guardian_________________________________________ Home Phone___________________________

Home Address ______________________________________________ Bus. or Cell Phone___________________

Mailing Address (if different from above)____________________________________________________________

Email Address _______________________ Home School District? (i.e. Brookside, Zone 99, etc.) _______________

Which school are you applying to? (circle only one) COLUMBUS JEFFERSON SILVERMINE

Do you currently have a child attending Columbus/Jefferson/Silvermine, if yes, complete below:

Other Children in Household:
Name Age School Grade
_____________________________________________________________________________________________

_____________________________________________________________________________________________

Grade applying for: (please circle) K 1 2 3 4 5

(For Silvermine you can only apply for K or 1)

Applicant’s Present School or Pre-School__________________________________________Grade______________

Address___________________________________________ Teacher’s Name_____________________________

Why do you want your child to attend the selected school? ______________________________________________

_____________________________________________________________________________________________

Parent/Guardian Signature____________________________________________________ Date_______________

Special Notes
 Siblings receive priority status.
 All official documentation pertaining to the School Lottery will be sent to the above mailing address.
 Applicants may apply to only one school.
 If applying for more than one sibling, separate applications must be completed for each child.

ALL APPLICATIONS MUST BE RETURNED BY MARCH 11, 2011 PLEASE RETURN TO:
COLUMBUS MAGNET SCHOOL JEFFERSON SCIENCE MAGNET SCHOOL SILVERMINE ELEMENTARY
46 CONCORD STREET 75 VAN BUREN AVENUE 157 PERRY AVENUE
SOUTH NORWALK, CT 06854 NORWALK, CT 06850 NORWALK, CT 06850