Kairos Enrollment Application
IMPORTANT NOTICE:
This form requests information charter schools are required to record if and when they enroll a student.
By law, answers to the questions will not and cannot affect your child's chance at admission through Kairos' enrollment lottery.
Information provided will be kept private as part of your child's education records.
Kairos is authorized to enroll students entering grades 6-8.
Applications for other grades are considered "interest forms" that will be shared with our Kairos Board and our sponsor as evidence of parent demand. If the Kairos Board and our sponsor approve authorizing additional grades, parents who submitted applications for those grades will be contacted to confirm interest in applying.
Have questions about Kairos? Contact our Chief Community Officer (info below).
Meet:
calendly.com/kairos-academies
Call: 314-607-0076
Email:
cco@kairosacademies.org
* Required
First Adult: General Information
This section requests information about YOU, the student's parent, guardian, caretaker, or adult point-of-contact.
First Adult: First Name
*
Your answer
First Adult: Last Name
*
Your answer
First Adult: Phone Number
*
Your answer
First Adult: Cell Phone Carrier
This ensures that you'll get messages through our automated communication system.
Choose
AT&T
Boost Mobile
Cricket Wireless
Google Project Fi
Republic Wireless
Sprint
Straight Talk
T-Mobile
Ting
Tracfone
U.S. Cellular
Verizon
Virgin Mobile
Metro PCS
First Adult: Email Address
*
Your answer
First Adult: Relationship to Student
*
Choose
Mother
Father
Stepfather
Stepmother
Aunt
Uncle
Grandfather
Grandmother
Brother
Sister
Cousin
Caretaker
Foster Parent
Other
First Adult: Legal Custody?
*
Do you have legal custody of the student? Are you authorized to enroll the student in a new school? (In the case of custody issues or court orders, please describe the terms in the "Other" line. Kairos will follow up for supporting documentation.)
Yes
No
Other:
First Adult: Annual Household Income?
The state and federal governments fund students at different levels depending on annual household income (e.g., reimbursements on free-and-reduced-priced lunches). To budget accordingly, we're requesting general census-style income information. Answers will not impact your registration at Kairos. To calculate the number of family members in your house, add: (i) yourself + (ii) your spouse/partner + (iii) the number of children (even if they don't live with you) who receive more than half of their support from you + (iv) the number of people (not children or spouse) who live with you and receive more than half of their support from you.
Family Members in House: 2
Family Members in House: 3
Family Members in House: 4
Family Members in House: 5
Family Members in House: 6
Family Members in House: 7
Family Members in House: 8
< $20,000 (less than $20,000)
$20,000-$30,000
$30,000-$40,000
$40,000-$50,000
$50,000-$60,000
$60,000-$70,000
> $80,000 (more than $80,000)
Family Members in House: 2
Family Members in House: 3
Family Members in House: 4
Family Members in House: 5
Family Members in House: 6
Family Members in House: 7
Family Members in House: 8
< $20,000 (less than $20,000)
$20,000-$30,000
$30,000-$40,000
$40,000-$50,000
$50,000-$60,000
$60,000-$70,000
> $80,000 (more than $80,000)
First Adult: Financial Assistance (Do you or your child currently receive...)
Like the previous question, this answer affects state funding and is required for budgeting purposes.
Food Stamps, a.k.a. the Supplemental Nutrition Assistance Program (SNAP)
Temporary Assistance for Needy Families (TANF)
Food Distribution Program on Indian Reservations (FDPIR)
No, I have never applied for or received any of the above.
Other:
First Adult: Medical Assistance
Like the previous question, this answer affects state funding and is required for budgeting purposes.
My child and/or I DO receive Medicaid.
My child and/or I DO NOT receive Medicaid.
Other:
Clear selection
Second Adult: General Information
If there is no second parent, guardian, caretaker, or point of contact, please skip this section.
Second Adult: First Name
Your answer
Second Adult: Last Name
Your answer
Second Adult: Phone Number
Your answer
Second Adult: Cell Phone Carrier
This ensures you'll get messages through our automated communication system.
Your answer
Second Adult: Email Address
Your answer
Second Adult: Relationship to Student
Choose
Mother
Father
Stepfather
Stepmother
Aunt
Uncle
Grandfather
Grandmother
Brother
Sister
Cousin
Caretaker
Foster Parent
Other
Second Adult: Legal Custody?
Does the second adult have legal custody of the student? (In the case of custody issues or court orders, please describe the terms in the "Other" line. Kairos will follow up for supporting documentation.)
Yes
No
Other:
Clear selection
Student: General Information
Student: First Name
*
Your answer
Student: Last Name
*
Your answer
Student: Phone
If the student has a phone number, otherwise leave blank.
Your answer
Student: Email
If the student has an email address, otherwise leave blank.
Your answer
Student: Date of Birth
*
MM
/
DD
/
YYYY
Student: Race
Choose
Black or African American
White
Hispanic or Latino
Asian
Middle Eastern or North African
Native American
Native Hawaiian or Other Pacific Islander
Two or More
Student: Ethnicity
Choose
Hispanic or Latino
Not Hispanic or Latino
Student: Gender Pronoun
Choose
Male ("he, him, his")
Female ("she, her, hers")
Neutral ("they, them, theirs")
Prefer not to say
Student: Schooling Information
Student: Current School Name
Your answer
Student: Current School City & State
St. Louis, Missouri
Other:
Clear selection
Student: Date Student Last Attended (approximate)
MM
/
DD
/
YYYY
Student: Other Schools Attended in the Past 24 Months
Your answer
Student: Current Grade Level (2019/2020 school year)
*
Choose
Pre-Kindergarten
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Student: IEP or 504 Plan
Does your child have an IEP (i.e., diagnosed learning disability) or 504 Plan? Please indicate the with which your child has been diagnosed:
No
I don't know. Please contact me so we can figure it out.
Yes: Learning Disabilities
Yes: Emotional Disturbance
Yes: Hearing Impairment
Yes: Speech Impairment
Yes: Language Impairment
Yes: Autism
Other:
Clear selection
Student: Disciplinary History
Has your child been expelled from another school for violations of school policies relating to weapons, drugs, or alcohol? (Answering falsely could result in your conviction of a class B misdemeanor.)
No
Yes
I don't know. Please contact me so we can figure it out.
Other:
Clear selection
Student: Record Release
To enroll at Kairos, you must authorize the students' previous school(s) to release student records to Kairos Academies. This is standard procedure, pursuant to state law, any time a student enters a new school. Kairos will request the following records from the students' previous school(s): health records, report cards, behavior/discipline reports (including Safe Schools Act violations), standardized test scores, 504 Plans, ELL plans, special education documentation (including evaluation reports and IEPs).
Yes, I authorize the release of my students' records.
I'm not sure. Please contact me so we can talk about this.
Other:
Clear selection
Student: Housing Information
School District of Residence
In accordance with Missouri Revised Statute 160.410.1 (2), Nonresident pupils eligible to attend a Kairos Academies under an urban voluntary transfer program; students from the county districts must be non-African American.
City of St. Louis City Public Schools
Affton
Bayless
Brentwood
Clayton
Hancock Place
Kirkwood
Ladue
Lindbergh
Mehlville
Parkway
Pattonville
Ritenour
Rockwood
Valley Park
Wester Groves
Clear selection
Student: Zip Code
*
Example: "63118."
Your answer
Student: Street Address
*
Example: "2315 Miami St." (Pursuant to state law, Kairos must rescind enrollment if you cannot prove residency at the address provided. For ways to prove residency, please see
www.tinyurl.com/KairosRegister
.)
Your answer
Student: Are you or the student currently...
Check all that apply. If none apply, please leave blank. If desired, use "Other" to add further explanation.
sharing the housing of other persons due to loss of housing, economic hardship, or a similar reason?
residing at a motel, hotel, in a car, or at a campsite because your home has been damaged or because of economic reasons?
residing in a shelter?
living in a temporary housing arrangement due to economic hardship?
Other:
Student: Did you or the student move in the past 36 months to obtain agriculture or fishing work?
A move qualifies if all the following are true: (i) it is a move across school district boundaries; (ii) it involves a change of residence; (iii) the purpose of the move was to obtain work in agriculture or fishing; (iv) the purpose of the move was not to relocate on a permanent basis; and (v) it occurred within the preceding 36 months.
Yes, our move matches the above criteria.
No, we have not.
I'm not sure. Please contact me so we can talk about this.
Other:
Clear selection
Student: Did the student immigrate to the United States in the past three (3) years?
Yes
No
I'm not sure. Please contact me so we can talk about this.
Other:
Clear selection
Is your child's parent or legal guardian in the US Military?
No
Yes: Active Duty
Yes: National Guard or Reserves
Yes: both Active Duty and National Guard / Reserve
Yes: ONLY the Armed Services Reserves or Part-Time National Guard
Clear selection
Student: Language Information
Student: What was the student's first language?
If not English, please write the language(s) in "Other."
English
Other:
Clear selection
Student: Which language(s) does the student speak at home?
If not English, please write the language(s) in "Other."
English
Other:
Clear selection
Student: Which language(s) does your child hear at home and understand?
If not English, please write the language(s) in "Other."
English
Other:
Clear selection
Community Building
What is your student's t-shirt size?
We'll be handing out Kairos t-shirts to families who complete every step in the Kairos registration packet (
www.tinyurl.com/KairosRegister
) by Kairos Community Day. (Don't worry if you're a few days late—your child will get a t-shirt as soon as you do submit!)
XS (US kids' letter)
S (US kids' letter)
M (US kids' letter)
L (US kids' letter)
XL (US kids' letter)
XXL (US kids' letter)
Clear selection
Would you like to join the Kairos Family Council (our PTA/PTO)?
If so, we'll follow up with more information in spring/summer.
Yes
No
Maybe
Other:
Clear selection
Do you know other families that we should contact about enrolling at Kairos?
Please put the names and contact information for parents of 3rd-5th graders who might want to learn more about Kairos (e.g., your student's classmates, friends, relatives). We'll reach out to them! If you don't know anybody, please leave blank.
Your answer
Would you be willing to host a small gathering of parents interested in learning more about Kairos, either at your home or at Kairos' offices?
If so, we'll follow up with more information. Kairos will organize all logistics.
Yes
No
Maybe
Other:
Clear selection
Submit
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