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Emerson Community Charter School 2019-2020 Lottery Form
Please complete this form if you live outside the attendance boundaries of Emerson Community Charter. Submit one application per child. If enrolling twins or triplets, each student must have their individual application. Duplicate submissions will result in only the LAST submitted application being valid.
Student Information
Please record name as it appears on school records and birth certificate.
First Name *
Your answer
Middle Name or Initial
Your answer
Last Name *
Your answer
Grade (August 2019) *
As the parent/guardian are you an employee of UCLA?
Date of Birth *
MM
/
DD
/
YYYY
Parent/Guardian Information
First Name of Parent/ Guardian *
Your answer
Last Name of Parent/ Guardian *
Your answer
Relationship to Child *
Your answer
Street Address *
Your answer
City *
Your answer
Zip Code *
Your answer
Phone Number *
Your answer
Additional Information
Does the student live within the attendance boundaries of Emerson? *
Does the Student have a sibling attending Emerson during the 2019-2020 school year?
Does the student live within the boundaries of the Los Angeles Unified School District? *
What school is your child currently enrolled in? *
Your answer
The School of Advanced Studies is a program designed for Gifted (GATE) and High Achieving Students. If chosen in the lottery, are you interested in the School of Advanced Studies? *
Placement in the school of advanced studies is dependent on supplemental information.
Parent/Guardian Statement
I understand that, upon acceptance into Emerson, a birth certificate or acceptable equivalent, proof of residence, proof of guardianship (if applicable), immunization records, and other applicable student records must be submitted as necessary for verification and enrollment purposes.

I understand that acceptance to Emerson Community Charter Middle School will be determined after all applicants from the lottery have been offered enrollment and if space permits.

I understand that any false or incorrect information on this application could jeopardize my child’s enrollment should he/she be selected to attend Emerson.

I understand that Emerson Community Charter Middle School DOES NOT provide transportation. Students enrolled through the Charter are NOT eligible to receive transportation to and from Emerson on a school bus through LAUSD. It is the parent/guardian's responsibility to provide transportation.

Under penalty of perjury, by electronically signing below, I certify that all information provided on this Lottery Application Form is true and accurate and we agree to adhere to Emerson Middle School Community Charter expectations. Information falsely provided in the application and/or students failing to follow any Charter policies and procedures may result in the student losing his/her Charter status and be returned to his/her school of residence. I have read the above agreement and accept the terms and conditions.

Parent/Guardian Electronic Signature *
Enter the first and last name of parent/guardian submitting form.
Your answer
Parent/Guardian Email *
PLEASE NOTE: All communication will be done via email. Please enter a valid email address
Your answer
Please Read
Emerson is a Los Angeles Unified School District affiliated charter school. Emerson does not discriminate against any student on the basis of disability, gender, gender identity, gender expression, nationality, race or ethnicity, religion, sexual orientation, or any other characteristic that is contained in the definition of hate crimes set forth in Section 422.55 of the California Penal Code.

The Los Angeles Unified School District does not provide transportation for students based on admission to a District affiliated charter school.

Please make sure all information is accurate and names are spelled correctly before submitting.
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