ADDRESS:
Street Name & Number
Apt# City State Zipcode
Phone Number Date of Birth School Currently Attending
Parent/Guardian Information
Who has the authority to apply for this child to attend Albany Community Charter School?
Mother/Stepmother & Father/Stepfather Mother/Stepmother Only Father/Stepfather Only Legal Guardian(s)
NAMES(S): First Middle Last
First Middle Last
Phone: Home Cell
Work
Special Needs Information
Has this student ever been evaluated to determine a need for any type of special education services?
YES, this student has been evaluated. Please complete the following:
Approxmate date of evaluation:
Services, if any, that were recommended:
Services, if any, currently receiving:
Evaluation was provided by: CSE Pediatrician Elementary School Other
NO, this student has never been evaluated.
Sibling Information
List the name, birth date, gender and September 2008 grade level of siblings of the student applying to Albany Community Charter School:
Name Date of Birth 2008 Grade
Name
Date of Birth 2008 Grade
I hereby testify that the information provided on this ACCS admission application is accurate and current.
Important Information for Admission: Upon admission, families must provide verification of residency, a copy of the student's prior year academic record, birth certificate and immunization record. In addition, student registration forms, lunch program applications and transportation forms must be completed.
