Charter Student Admission Application
Betty M. Condra School for Education Innovation
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Which year? *
Student Last Name *
Student First Name *
Student Middle Name *
Suffix
Student Social Security Number or Student ID
Date of Birth *
MM
/
DD
/
YYYY
Grade Applying For *
Do you have another student at this Charter School? *
Is this a child of a staff or board member *
Primary Guardian Last Name *
Primary Guardian First Name *
Street Address *
City *
State *
Zip Code *
Telephone Number *
Email Address *
CERTIFICATION (Required): By checking below box, I certify to the best of my knowledge and belief that the information in this application is complete and accurate, I am the legal guardian of the child listed above, and I understand that any false information, omission, or misrepresentation of facts may result in the rejection of this application or future dismissal of the applicant. CERTIFICACION (Requerida): Al marcar esta casilla, certifico a mi leal saber y entender que la información en esta solicitud es completa yprecisa, soy el tutor legal del niño mencionado anteriormente, y entiendo que cualquier información falsa, omisión, o la tergiversación de loshechos puede resultar en el rechazo de esta solicitud o en el futuro despido del solicitante. This school does not discriminate on the basis of sex, national origin, ethnicity, religion, disability, or academic or athletic ability.(Esta escuela no discrimina por sexo, origen nacional, etnia, religión, discapacidad, or capacidad académica o atlética.) *
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