2017-18 2nd Year Application-Intent to Return BTC
What is your first name?
Your answer
What is your last name?
Your answer
What is your birth date?
MM
/
DD
/
YYYY
What grade are you going into?
Mailing Address
Your answer
Mailing City
Your answer
Mailing Zip
Your answer
Legal Town of Residence
Your answer
Student email address
Your answer
Student cell phone #
Your answer
Home Phone
Your answer
Parent/Guardian 1 Name
Your answer
Parent/Guardian 1 Primary Phone #
Your answer
Parent/Guardian 1 Street Address
Your answer
Parent/Guardian 1 City
Your answer
Parent/Guardian 1 State
Your answer
Parent/Guardian 1 Zip Code
Your answer
Parent/Guardian 1 Email Address
Your answer
Parent/Guardian 2 Name (If applicable)
Your answer
Parent/Guardian 2 Primary Phone #
Your answer
Parent Guardian 2 Street Address (If different than Parent 1)
Your answer
Parent/Guardian 2 City (If different than Parent 1)
Your answer
Parent/Guardian 2 State (If different than Parent 1)
Your answer
Parent/Guardian 2 Zip Code (If different than Parent 1)
Your answer
Parent/Guardian 2 Email Address
Your answer
What is your home High School?
Required
What program are you returning to (2nd Year)?
Required
Applicants for admission and employment, students, parents, employees, sources of referral of applicants for admission and employment, and all unions or professional organizations holding collective bargaining or professional agreements with the Burlington School District are hereby notified that it is the intent of the Burlington Board of School Commissioners that the District will not discriminate against employees and/or applicants for employment, students or other designated beneficiaries of the statutes listed below on the basis of race, sex, gender (including but not limited to pregnancy and parental status), color, age, creed, religion, disability, handicap, ancestry, place of birth, national origin, marital status, political affiliation, sexual orientation, gender identity or gender expression in any of its employment and education practices, policies, procedures or decisions or in the operation of, access to, participation in, benefit of or admission to its programs, activities, services and facilities and that it will provide equal access to the Boy Scouts of America and other designated youth groups in compliance with and to the extent provided by the laws listed below. The District’s Title VI Coordinator, the Age Discrimination Act Coordinator and Americans with Disabilities Act Coordinator for employees and others: Nikki Fuller, Human Resources Director, Burlington School District (802) 864-2159; 1-800-253-0191 TDD The District’s Title IX Coordinator for employees, students, parents and other such relatives, friends, guest speakers or visitors: Henri Sparks, Director of Equity, Burlington School District (802) 865-4168; 1-800-253-0191 TDD The District’s Americans with Disabilities Act Coordinator for students and 504 Coordinator: Director of Special Services of the Burlington School District (802) 864-2159; 1-800-253-0191 TDD
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