APPLICATION FOR ENROLLMENT LOTTERY Student Information

Family Information

Student’s first name:

Mother/guardian name:

Student’s middle name: Student’s last name:

Address (if different):

Home Address: Cell phone number:

Work phone number:

Mother’s Email address:

Home phone: Gender:

M

F Father/guardian name:

Date of birth (mm/dd/yyyy):

City/State of Birth: Address (if different):

Grade applying for in Fall 2016: Cell phone number: K

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2

3

4

5

6

7

Work phone number:

8 Father’s Email address:

Age as of September 1, 2015:

Today’s Date: Sibling Information If you have other children attending River Valley Charter School, please complete the following: Full name:

If you have other children applying to or on the RVCS waitlist, please complete the following: Full name:

Age:

Age:

Grade:

Full name:

Grade:

Full name:

Age:

Grade:

Age:

Grade:

Offers of admission are made in writing or by telephone. Please keep your contact information up to date.

Do you wish your child to be automatically re-enrolled in subsequent lotteries through grade eight? Yes No Please circle one

Parent Signature Current School

Printed Name

Date Town/City

River Valley Charter School complies with all applicable Commonwealth and Federal Law having to do with non-discrimination and does not discriminate on the basis of race, color, national origin, creed, sex, gender identity, ethnicity, sexual orientation, mental or physical disability, age, ancestry, athletic performance, special need, proficiency in the English language or a foreign language, or prior academic achievement in its educational programs or activities pursuant to Massachusetts General Laws, Chapter 151B and 151C, Title VI of the Civil Rights Act of 1964; Title IX of the Education Amendments of 1972; M.G.L. c76,s5, Section 504, Rehabilitation Act of 1973; Americans with Disabilities Act, and regulations promulgated thereunder, 34 C.F.R. Part 100 (Title VI), Part 106 (Title IX) and Part 104 (Section 504).

Please return the completed application, a copy of your child’s birth certificate and a current utility bill as proof of residency to the River Valley Charter School, 2 Perry Way, Newburyport, MA 01950

For translation or interpretation services, please contact the office at 978.465.0065