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Applicant's First Name
Middle Name
Last Name
Address
Apt. #
City
State
Zip
Birthday (MM/DD/YYYY)
Gender	Male Female
Social Security Number
Email Address
Demographics
Location:
Grade Level Applying For:
Extra Curricular activities that you might wish to participate in while at NCLB. CHOICE 1
Extra Curricular activities that you might wish to participate in while at NCLB. CHOICE 2
Extra Curricular activities that you might wish to participate in while at NCLB. CHOICE 3
If you cannot be reached please list 2 emergency contacts with information. Main Emergency Contact's Name
Relationship to Child
Phone Number
Alternate Phone Number
Email Address
Address
City
State
Zip Code
Has permission to pick up child during or after school. (Check if yes)
Alternate Emergency Contact's Name
Relationship to your child
Phone Number
Alternate Phone Number
Email Address
Address
City
State
Zip Code
Has permission to pick up child during or after school. (Check if yes)
Last school your child attended
Last school's address:
City
State
Zip Code
Has your child ever attended a Charter School before?	Yes No
If yes, please list the name of the school:
Dates Attended (MM/YYYY - MM/YYYY)
Standardized Test Score

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