Barack Obama Charter School
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**** Open Enrollment for New Students Ends March 29th **** Re-Enrollment for Current BOCS Students Ends April 20th ****
Application for Admission
Please complete the form below. Mandatory fields marked
*
SELECT TERM
(Please select
ONLY
one term to indicate when student will
BEGIN
attending Ingenium Charter School)
*
2011–12 (mid-year transfer)
OR
2012–13 (Fall 2012 New Enrollment)
Applicant Information
Last Name
*
Middle Name
First Name
*
Current Grade (Fall 2011)
*
-- Select --
PK
K
1
2
3
4
5
6
Gender
*
Male
Female
Street Address
*
City
*
State
*
-- Select --
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip
*
Telephone #
*
Age
*
Birthdate
*
--Select--
JANUARY
FEBRUARY
MARCH
APRIL
MAY
JUNE
JULY
AUGUST
SEPTEMBER
OCTOBER
NOVEMBER
DECEMBER
--Select--
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
(XXXX)
Birth City / State / Country
*
-- Select --
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
What is your child's Ethnicity?
Used for state and federal reporting purposes. Please check all that apply.
Hispanic (500)
American Indian or Alaskan Native (100)
Laotian (206)
Samoan (303)
Chinese (201)
Cambodian (207)
Tahitian (304)
Japanese (202)
Hmong (208)
Other Pacific Islander (399)
Korean (203)
Other Asian (299)
Filipino/Filipino American (400)
Vietnamese (204)
Hawaiian (301)
African American or Black (600)
Asian Indian (205)
Guamanian (302)
White (700)
Student Details
Has the student ever . . .
At Risk of retention Receives Intervention
*
Yes
No
Has the student been enrolled in local public schools?
*
Yes
No
Has the student received Special Education Services?
*
Yes
No
Does the student have a current IEP?
*
Yes
No
Has the student been in the Gifted Program?
*
Yes
No
Previous School
Last School Attended
Name of School
*
Address
*
City
*
State
*
Zip
*
Parent Information
Parent 1
Parent/Guardian Education Level (Used for state and federal reporting purposes)
-- Choose --
Not a high school graduate
High school graduate
Some college
College graduate
Grad school/postgrad training
Last Name
*
First Name
*
Relationship to Student
*
Lives with
*
Yes
No
Address (If different from student)
Occupation
*
Employer
*
Employer's Address
*
Home Phone
*
Cell Phone
*
Work Phone
*
Email
Parent 2
Parent/Guardian Education Level (Used for state and federal reporting purposes)
-- Choose --
Not a high school graduate
High school graduate
Some college
College graduate
Grad school/postgrad training
Last Name
*
First Name
*
Relationship to Student
*
Lives with
*
Yes
No
Address (If different from student)
Occupation
*
Employer
*
Employer's Address
*
Home Phone
*
Cell Phone
*
Work Phone
*
Email
What is the Primary Language Spoken in the home?
*
*
My signature below certifies that all the information requested on this Enrollment Application Form is true and accurate.
Signature
*
Date
*