The Soulsville Charter School The Soulsville Charter School is a

The Soulsville Charter School The Soulsville Charter School is a

Application Date: The Soulsville Charter School Student Name: ___________________ 1115 College Street Memphis, TN 38106 901.261-6366 ____________...

NAN Sizes 0 Downloads 6 Views

Recommend Documents

Charter School - The Villages Charter Schools
Academic Success. • The Villages High School has now earned 11 straight. A's (2006-2016). VHS is one of only 25 high s

leap academy charter school - LEAP Academy University Charter School
Sep 13, 2016 - Meeting called to order by Dr. Gloria Bonilla-Santiago at 6:00 pm. Attendance: Present: Gloria Bonilla-Sa

Charter School - Bauder
Broughton House, Broughton Road, Ipswich IP1 3QR England. O'Duffy Centre, Cross Lane, ... Specifier: Penoyre & Prasad Ar

webquest - Moscow Charter School
... be discussing later this week. The books: - The BFG. - The Witches. - James and the Giant Peach. - Charlie and the C

Vance Charter School Newsletter
Apr 7, 2017 - Daniel & Heather Richardson. Brian & Allison Cloninger. Kim Richardson. Brian & Renee Daniel. Charles & Di

October - Northshore Charter School
Oct 4, 2017 - 25. 26. 27. 28. 29. 01. 30. 02. 03. 04. 05. 06. 08. 07. 09. 10. 11. 12. 13. 15. 14. 16. 17. 18. 19. 20. 22

itinerary - HighMark Charter School
Grauman's Chinese Theatre - TCL Chinese Theatre (formerly Grauman's Chinese Theatre, and Mann's. Chinese Theatre) is a m

Application Date:

The Soulsville Charter School

Student Name:

___________________

1115 College Street Memphis, TN 38106 901.261-6366

____________________

(completed by school)

The Soulsville Charter School is a highly disciplined, academically rigorous, college preparatory school. We are determined to provide all of our students with a world-class education that will enable them to open doors of opportunity. Mission Statement The Soulsville Charter School will prepare students for success in college and life in an academically rigorous, music-rich environment.

Program Enrichment • Rigorous Academics • Character Education • Highly Structured Learning Environment • Extended School Day Hours – (7:40 am – 3:30 pm M -Th; 7:40 – 2:15 pm F)* • Summer Term • Saturday School • Soulsville Symphony Orchestra- Music Instruction • Leadership and Volunteer Activities *Students who have Assigned Mandatory Tutoring are dismissed at 4:30pm on the days they have tutoring.

Comprehensive Student Services • • • • • • •

Mentoring Academic Tutoring Health Referrals Social Referrals Study Skills and Test Preparation College Guidance Alumni Support

The Soulsville Charter School’s has a unique collection of workshops, field trips, guest speakers, and special opportunities that support and enhance the core curriculum.

To be completed by the parent Please let us know for which grade(s)/year(s) your child is applying for admission to The Soulsville Charter School. (You may apply for a 2013-14 waitlist spot and a 2014-15 spot by checking the applicable blanks.) 2015 – 2016 ____ 6th grade (Waitlist Only) ____ 7th grade (Waitlist Only) ____ 8th grade (Waitlist Only) ____ 9th grade (Waitlist Only)

2016 – 2017 ____ 6th grade ____ 7th grade ____ 8th grade ____ 9th grade

2016 - 2017 ____10th Grade (Waitlist Only)

According to Tennessee law, a student may enroll at a charter school if he/she resides within the jurisdiction of Memphis City Schools.

Student Name

Sex First

Middle

Home Address

City

Home Telephone

SSN

Date of Birth

City/State of Birth

School last attended Has student ever repeated a grade? Yes No If yes, state reason and grade

Has student ever had any disciplinary difficulty in school? Yes No If yes, describe briefly

Age

Last St _____Zip

To Be Completed by Students Why do you want to attend The Soulsville Charter School? (25 words or more – you may use more paper)

__________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________

Please complete one application per child. Child's Name (Please print clearly)

first

middle

last

Date of Birth

Home address address

city

state

zip

Is this address on federal property? Yes No Is English the primary language spoken by student? Yes No If no, home language Is English Language limited? Yes No Is your child enrolled in or has your child ever been enrolled in any of the following? Special Education or Resource Program 504 Speech/Language Therapy If yes, please describe

Is parent/guardian on active military duty? Yes No If yes, which branch of service? Is parent/guardian employed on federal property? Yes No If yes, where? Adults living with applicant: Mother Father Guardian How will your child get to school if enrolled? Bus Drop-off Walk Other Does your child have computer access at home? Yes No Does your child have Internet access at home? Yes No

Stepmother Stepfather Grandmother

Grandfather Other

01/25/2016

Mother’s Information Mother's Name

Social Security # (Please print)

Address City State Zip Email Address ____________________________________ Employer Work Address City

State

Check Applicable Status: Married Divorced

Home Phone

Work Phone Work Days Work Hours

Zip

Separated Single

Widowed

Father’s Information Father's Name

Social Security # (Please print)

Address City State Zip Email Address ____________________________________ Employer Work Address City

State

Check Applicable Status: Married Divorced

Home Phone

Work Phone Work Days Work Hours

Zip

Separated Single

Guardian Information (If different than #1 or #2) Name

Widowed

Social Security #

(Please print)

Address Home Phone City State Zip Email Address ____________________________________ Employer Work Address City Check Applicable Status: Married Divorced

State

Work Phone Work Days Work Hours

Zip

Separated Single

5

Widowed

01/25/2016

With whom does the child live? Mom Dad Both Please list any schools or day cares attended by applicant. School

List of all other children in family. Name

City

Age

State

Dates

School

Grade

Have any of the child's brothers or sisters attended the Stax Music Academy programs? Yes No If yes, give name of child, program, and dates attended (Use back of this page if necessary)

Print Name

Program

Date

6

01/25/2016

Medical Information It is the responsibility of the Parent or Guardian to provide the school with specific emergency procedures The history is required primarily to determine what adjustments, if any, should be made in schedules of activities to meet the individual needs of participants, and that the applicant may safely participate in those activities. PERSONAL HISTORY Check beside those medical problems the applicant has had or currently has

( ( ( ( ( ( ( ( ( ( ( ( ( (

) ) ) ) ) ) ) ) ) ) ) ) ) )

Measles (Rubella) Rubella (3-day measles) Mumps Chicken pox Thyroid Sinusitis Eye trouble Ear trouble Throat problems Hypoglycemia Joint problems Sickle cell anemia Hernia Cancer

( (

) )

Insomnia Tension or depression

( ( ( ( ( ( ( ( ( ( ( ( ( ( ( (

)

Frequent headaches

) ) ) ) ) ) ) ) ) ) ) ) ) ) )

Head injury Hay fever, asthma Tuberculosis Jaundice, liver disease Stomach, intestinal trouble Fainting Allergies Diabetes Seizure disorder/Epilepsy Kidney, bladder problem Chest pain Chronic pain Palpitations High blood pressure Heart problem or murmur

( ( ( ( ( (

) ) ) ) ) )

Rheumatic fever Sexually transmitted diseases Gall bladder trouble Neurological disorder Pneumonia Ankle sprains & Knee injuries ( ) Mild ( ) Mild ( ) Severe ( ) Severe

(

)

Other ______________________

FEMALE ONLY: ( ( (

) ) )

Irregular periods Severe cramps Excessive flow

USE ADDITIONAL SHEET IF NECESSARY Please comment in detail in the space below on any medical condition checked in Personal History.

_________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ List any medications applicant is receiving regularly (medications that are required by applicant should accompany him/her at School)

List any other health or personal concerns that Soulsville Charter School should be aware of regarding the applicant.

_________________________________________ _________________________________________ _________________________________________ Does applicant have any health problem that requires periodic evaluation or testing? ( ) Yes – give details ( ) No

_________________________________________ _________________________________________

_________________________________________

_________________________________________

_________________________________________

List drugs or food which applicant is allergic to:

_________________________________________

_________________________________________

_________________________________________

_________________________________________

_________________________________________

_________________________________________

7

01/25/2016

NOTICE: If your child requires medication/or medical procedures at school, an authorization form must be completed by your physician and signed by you before medication can be self-administered.

All medication must be in its original labeled container and marked with the student’s name. All medication, even over the counter, must be kept in the office with the exception of asthma inhalers and epi pens. An authorization form must be completed for the asthma inhalers and epi pens as well.

Emergency Information Name of adult authorized to act for parent in emergency situations when the parent cannot be reached (also give relationship to child): Name (please print) Relationship to Child Home Address City

Home Phone State

Zip

Name of Employer Work Address City

Work Phone State

Zip

Child's Doctor

Telephone

Name of Clinic Address

City

State

Hospital of Choice Insurance Company

Policy/Group#

8

Zip

01/25/2016

Emergency Treatment Release In the event of an emergency when I cannot be reached, the person named above is authorized to act on my behalf regarding the welfare of . I hereby authorize The Soulsville Charter School (Print Child’s Name)

to transport this child to seek proper medical care. I also authorize the doctor or hospital to treat my child in the event of an emergency. _______________________ Date

Signature Parent/Guardian

Parent/Guardian’s name (please print)

Parent/Guardian Authorization Field Trip Permission Slip My child,

, has my permission to go on any Field Trips conducted (Please print)

by staff members/volunteers of Soulsville Charter School. I release Soulsville Charter School of all responsibility other than reasonable care. We will take trips by walking or riding (bus, van, or car).

Signature Parent/Guardian

Date

Activities Permission Slip My child,

, has my permission to take part in physical activities, (Please print)

and I agree to release Soulsville Charter School and its employees, exercising reasonable care, from liability for injuries resulting from or occurring during these activities.

Signature Parent/Guardian

Date

Photographs Permission Slip I give The Soulsville Charter School permission to have pictures taken of my child, for publicity, school records, and/or school activities.

Signature Parent/Guardian

Date

9

, (Please print)

01/25/2016

Child Release Form The following people are authorized check out during regular school hours. Name

from The Soulsville Charter School (Print Child's Name)

Relation to child

Home Phone

Work Phone / / / /

________________ Parent/Guardian Signature

Date

Students By signing this application, I am indicating that I understand that I must read and sign a commitment contract before I enroll in The Soulsville Charter School. I have discussed my decision to attend the school with my parent or guardian. I agree to abide by the school’s rules and policies. I also fully understand that the use or possession of a weapon, alcoholic beverages, tobacco, narcotics and any other substance abuse is forbidden. This rule applies for my entire school career (including summer vacations) and also applies both on and off The Soulsville Charter School campus. If I change my mind concerning the rules, I will accept the responsibility for my actions. ____________________________________ Student Signature

_____________________ Date

Parents or Guardians I have read and understand this request for admission and accompanying information. I have also discussed with my child his/her decision to attend The Soulsville Charter School, and believe that all the statements made are true, to the best of my ability. In making this request for admission, I accept, on behalf of my child, the principles of the school and I further understand that: 1. The teacher has full discretion to give detentions to my student if he/she violates classroom discipline policies. 2. The school reserves the right to dismiss my student if he/she does not respect its disciplinary standards or cooperate in the educational program or if I the parent/guardian do not support school policies as outlined in the Commitment to Excellence Agreement. ____________________________________ Student Signature

_____________________ Date

10