Application Status:  Date Received_____________Attendance Records_______Date Admitted_______________

 

Chrysalis Charter School Application

 

 

 

Child’s Name____________________________________Date of Birth____________________

 

Gender  M   F        Grade applying for during the 2008-2009 school year:   K  1  2  3  4  5  6  7  8

 

School Currently Enrolled In _________________________________Current Grade _________

 

Public School District of Residence ________________________________________________

 

Please include with this application a copy of your child’s school attendance records for the last 12 months.

 

Parent Information:

 

Name ________________________________________________________________________

 

Street Address__________________________________________________________________

 

City ________________________________________________Zip_______________________

 

Home Phone ____________________________Work Phone ____________________________

 

E-mail _______________________________________________________________________

 

Important Points to Initial as they apply:

 

_____ This child has been home schooled by parents in the past for ______ years.

 

_____ This child has special needs and has an existing, written Individual Educational Plan (IEP)  (This will not exclude a child, but requires special procedures.) Include a copy of your IEP with your application.

 

_____I am aware that enrollment at Chrysalis requires parent participation and service for a minimum of 40 hours a  

           year.

 

_____I understand that declining to accept an enrollment opening during the school year will result in my child’s name being removed from the waiting list.

 

How did you learn about Chrysalis School?  Friend _______   Parent Magazine ________ Newspaper _________     

Phone Book _________   Your Website _________ Other ____________________________________________

 

 

Parent Signature __________________________________

 

Mail to Chrysalis Charter School, P.O. Box 709, Palo Cedro, CA  96073-0709

Fax  to (530) 547-9734

For information, call (530) 547-9726.