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Intent to Apply for Student Admission: 2016 – 2017

ACCS-Enrollment-Form-2016-2017

For help completing this form, please call 518-433-1500

Student Name

First*
Last*

Address

Street*
City*
State*
Zip*
Phone Number*
Date of Birth*
School Currently Attending
GradeLevelApplyingFor:
K 1st 2nd 3rd 4th 5th 6th 7th 8th

Parent/Guardian Information

Who has the authority to apply for this child to attend Albany Community Charter School?

Please list the names of those applying for this child:

First*
Last*
First
Last
Street*
City*
State*
Zip*
Email*
Home* Phone Number
Mobile Phone Number
Work Phone Number

Special Needs Information

Has this student ever been evaluated to determine a need for any type of special education services?

Approximate date of evaluation

Services, if any, that were recommended

Services, if any, currently receiving

Evaluation was provided by

Sibling Information

Name
Date of Birth
Current Grade
Name
Date of Birth
Current Grade

I hereby testify that the information provided on this ACCS admission application is accurate and current.

Important Information for Admission: Upon admission, families must provide verification of residency, a copy of the student's prior year academic record, birth certificate and immunization record. In addition, student registration forms, lunch program applications and transportation forms must be completed.