15-16 School Year STUDENT ID #_______________

DATE_________________

CHRISTOPHER COLUMBUS CHARTER SCHOOL

INTENT TO REGISTER

Student Information (Please print)

Name___________________________________________________________________________

Last First Middle

Address_________________________________________________________________________

City____________________ State____________________ Zip Code_______________

Phone ( ) ______________________ Cell Phone ( ) ____________________

Grade Entering : K 1 2 3 4 5 6 7 8 (2015-2016)

E-Mail Address_________________________ Confirm E-mail address_________________________

Gender: Male / Female Date of Birth________________________

KINDERGARTEN APPLICANTS

KINDERGARTEN CHILD MUST BE 5 BY SEPTEMBER 1, 2015

PRE-K YOUR CHILD CURRENTLY ATTENDS____________________________

Specify primary language spoken at home if other than English_______________________________

Sibling Information

Does the student have a sibling currently enrolled at CCCS?

Sibling is defined as a brother or sister living in the same household.

If so, Sibling’s name __________________________________

Grade in 14-15 _______________

REQUIRED DOCUMENTS

Proof of residency in Philadelphia County (a recently dated PECO or PGW bill, a current vehicle registration card, or a recent pay stub)

PARENTAL INFORMATION

PARENT/LEGAL GUARDIAN (Please print)

_________________________________________________________________________________

Last First Middle

Address__________________________________________________________________________

City____________________ State____________________ Zip Code________________

Home Telephone Number _________________ Work Telephone Number _________________

Cell Telephone Number _________________ E-mail address ______________________________

Relationship to child? _______________________________________________________________

_________________________________________________________________________________

Last First Middle

Address__________________________________________________________________________

City____________________ State____________________ Zip Code________________

Home Telephone Number _________________ Work Telephone Number _________________

Cell Telephone Number _________________ E-mail address ________________________________

Relationship to child? _______________________________________________________________

I certify that the information provided is accurate and complete. I understand that any false information will void this intent to register.

__________________________ ______________

Parent’s/Guardian’s Signature Date

__________________________ ______________

Parent’s/Guardian’s Signature Date

Kindergarten applications are due by January 31, 2015

Grades 1-8 will be accepted until May 1, 2015

Lottery for Kindergarten will be held on February 12, 2015

CCCS does not discriminate against any child – all are considered equal regardless of race, sex, sexual orientation, religion or beliefs.

INTENT TO REGISTER DOES NOT GUARANTEE ACCEPTANCE.