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Application Status: Date
Received___________ Grades_______Attendance _______Date Admitted___________ Chrysalis Charter School Application
Child’s Name____________________________________Date of Birth____________________
Applying
for which program? Full time (classroom) __________ Home School
_________ Gender M F Grade applying for during the
2009-2010 school year: K 1 2 3 4 5 6 7 8 School Currently Enrolled In _________________________________Current Grade _________ Public School District of Residence ________________________________________________
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.)
_____
Has your child been SARBed?
_____ Suspended?
______ Expelled? _____I am aware that enrollment at Chrysalis requires 40 hours a year of parent participation and service. _____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? Friend ___ Parent Magazine ___ Newspaper ____ Phone Book ___ Your Website ___ Other _________________________________________ Please include with this application: A copy of your child’s school report card (for placement purposes) and attendance records for the last 12 months A copy of your child's IEP or 504 plan, if your child has one Parent Signature __________________________________ Mail to Chrysalis Charter School, P.O. Box 709, Palo Cedro, CA 96073-0709 Fax to (530) 547-9734 |