BARNSTABLE COMMUNITY HORACE MANN CHARTER PUBLIC SCHOOL

SCHOOL CHOICE APPLICATION FORM

2017-2018 SCHOOL YEAR

Applications will be accepted on weekdays from Thursday, May 10, 2017 until 12:00 pm on Monday, June 12, 2017, in order to be eligible. The lottery if needed will be held at 2:30 pm on June 12, 2017.

CHILD’S NAME______DOB______Place of Birth______

MM/DD/YYYY

LAST FIRST MIDDLE

GENDER M/F
______
CHILD’S ADDRESS:

GRADE APPLYING FOR:

PRESENT SCHOOL: PRESENT GRADE:

Child’s Primary Language:______Parent’s Primary language:______

Name of any day care or after school program child has attended:

Parent/Guardian #1Name______


Parent/Guardian #1Address______

Parent/Guardian #1 Home Phone: ( )______Mother’s Work Phone: ( )______

Parent/Guardian #1 Cell Phone: ( )______Parent/Guardian #1 E-mail______

Parent/Guardian #2 Name______

Parent/Guardian #2 Address______

Parent/Guardian #2 Home Phone: ( )______Parent/Guardian #2 Work Phone: ( )______
Parent/Guardian #2 Cell Phone: ( )______Parent/Guardian #2 E-mail______

Other Children in family:

Name Date of Birth Check if Sibling at BCHMCPS ______

______

See reverse for required documentation. Applications received without these documents will not be entered into the lottery.

This application must be accompanied by the following documents:

1. Proof of child’s age – one of the following

·  Birth certificate

·  Baptismal certificate identifying date of birth

·  Hospital record indentifying date of birth

2. Proof of Residency: one or more records from EACH category

Category A / Category B / Category C
·  Deed and/or record of mortgage payment made within the past 45 days; or
·  Copy of current lease and record of rental payment made within the past 45 days; or
·  Notarized Barnstable Public Schools Landlord Affidavit and proof of rental payment made within the past 45 days. / ·  Utility bill dated within the past 45 days, such as oil, gas, electric, cable bill, renter’s insurance bill, car insurance bill, or home telephone bill. / ·  Valid Massachusetts Driver’s license; or
·  Current Motor Vehicle Registration; or
·  Valid government-issued photo identification; or
·  IRS Form W-2; or
·  Excise Tax Bill; or
·  Payroll Stub; or
·  Voter Registration