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Byron Center Charter School 2017-2018 Enrollment
Byron Center Charter School does not discriminate on the basis of race, color, national origin, sex, age, disability, religion, height, weight, or marital status in its programs and activities.
Email address
How did you hear about Byron Center Charter School, if referred who referred you?
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Grade Entering
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Student's Legal Last Name:
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Student's Legal First Name:
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Student's Legal Middle Name:
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Street Address
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City
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State
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Zip Code
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Birth Date
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Age:
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Gender
Home Phone:
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Email (for school news etc.):
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Ethnicity (select all that apply):
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Student resides with (check all that apply)
Student's Language:
Home Language:
Enrollment history (for new students only): Does your child receive any of the following services?
Is your student currently expelled, suspended, or recommended for expulsion or long-term suspension?
School previously attended:
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Parent/Guardian, FATHER: (last,first)
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Relationship to student: (Father, Step Father, etc.)
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Place of Employment:
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Daytime/Cell Phone Number:
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Address (if not same as student's)
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Parent/Guardian, MOTHER: (last,first)
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Relationship to Student: (Mother, Step Mother, etc.)
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Place of Employment:
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Daytime/Cell Phone Number:
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Address: (if not the same as student's)
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Emergency Contact Name 1 (last,first:)
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Emergency Contact Phone Number: (specify home, cell etc.)
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Emergency Contact Name 2 (last, first)
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Emergency Contact Phone Number: (specify home/cell etc.)
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Medical Information: Please tell us if your student has any medical conditions, allergies or takes any medication that you feel we should be aware of:
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I hereby give permission for my student to be transported in a vehicle and participate in field trips. I understand that field trips are a part of the school's educational program and provides a learning experience of educational value to my student.
I hereby give permission to Byron Center Charter to secure emergency medical treatment for the above named student while in their care. Release and agree to hold the Board of Education, its officials and its staff harmless from any and all liability for damaged or injury resulting directly or indirectly for this authorization. I understand that the school staff is not medically trained.
I affirm, that as the parent/legal guardian, all information provided above is true and accurate, and that my student and I reside at the listed address. I understand any false information provided by me, may subject me to legal penalties for perjury.
Byron Center Charter School is authorized to use our son/daughter's photo/video in school publications/advertisements to promote events and or enrollment in local media, unless a written objection is filed with the office within 30 days of enrollment.
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