The Ida B. Wells Community Academy

Sponsored by the Ohio State Department of Education and
the Ida B. Wells Community Academy, Inc., and
hosted by St. Paul's Baptist Church, 1350 Virginia Avenue
Akron, Ohio 44306-3603

PRE-REGISTRATION FORM FOR ACADEMIC YEAR 2001-2002*

Return This Pre-Registration Form to:
Headquarters, The Ida B. Wells Community Academy, Inc.  ATTN: Ms. Anderson
670 Wooster Avenue, Akron, Ohio   44307-1868 


(Please Print or Type Your Responses to Each Item)

 1. Name: _________________________________________________ Date: ________________________

 2. Home Address: _______________________________________________________________________
                                     Street                               City                       State                        Zip

 3. Telephone Numbers (home) ____________________ (work) _____________________

 4.  It is now possible for child(ren) to attend the Academy #2 if they live outside the Akron Public School District. 
     Should you be interested or know someone who is interested in doing so, contact Pastor Clifton Norwood at
     330.773.0999   OR   Ms. Angela M. Anderson at 330.376.4915.

 5. Number of children in family? __________

     a. Number male: __________ Number female: __________

     b. Please give the name, age, birth date and Social Security Number of each child you wish to enroll: 

         (1) _________________________ Age ______ Date of Birth ________________ SSN: __________________

         (2) _________________________ Age ______ Date of Birth ________________ SSN: __________________

         (3) _________________________ Age ______ Date of Birth ________________ SSN: __________________

 6. What school(s) do they attend? (1) ______________ (2) ______________ (3) _______________ 

 7. What grades are they in? (1) _______________ (2) _______________ (3) _______________ 

 8. Has any of them ever been retained?  Yes _______ No _______ If yes, what grade(s)? 

_________________________________________________________________________________________________

     Why were they retained? _________________________________________________________________________

 9. Has any of your children been suspended or expelled? Yes ________ No ________

     If yes, when and why? ___________________________________________________________________________

_________________________________________________________________________________________________

10. Do your children have special educational needs? Yes ________ No ________ 

      If yes, explain:  _________________________________________________________________________________

_________________________________________________________________________________________________

11. Are your children eligible for the Free School Lunch Program? Yes _______ No ________

12. Are you or your children on any kind of Public Assistance program? Yes ______ No ______ 

13. If yes, what program(s)? _________________________________________________________________________

________________________________________________________________________________________________

14. Has(have) your child(ren) been immunized? Yes ______ No ______ If yes, against what diseases?

_________________________________________________________________________________________________

15. Is your child(ren) on any medications? Yes ______ No ______ What kinds? _______________________________

_________________________________  and for what? ___________________________________________________

16. Would you be interested in serving on the Ida B. Wells Community Academy #2's Site Management Council, if 
     your child(ren) is(are) enrolled? Yes ______ No ______

17. Provide a brief statement describing your reasons for having your child(ren) attend this FREE public Community
     School sponsored by the Ida B. Wells Community Academy, Inc., headquartered at 670 Wooster Avenue, and 
     funded by the Ohio Department of Education. (If you need more space, add additional sheets of paper.)

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

18. Do you know anyone who would consider enrolling their child(ren) in the Ida B. Wells Community Academy #2? 

     Yes ______ No ______ If yes, would you, please, instruct them to write or call for a Pre-Registration Form.

19. Can you provide transportation for your child(ren) if they missed the school bus? Yes ______   No ______ 
      This is not required for your child(ren) to attend Academy #2. The Akron Public Schools must BY LAW transport
      all Community School children in Akron, Ohio.

20.  Parent participation in the Governance and Planning of the Ida B. Wells Community Academy #2's operation and 
      decision making process is requested so that you will have first hand knowledge of and can participate in all of its 
      aspects. This is essential for your child(ren)'s success in school. Are you willing to volunteer and participate in a 
      training and orientation program designed to inform you more in-depth on the Ida B. Wells Community Academy #2
      educational process and practices? Yes _______ No _______ Your participation in Academy #2's activities is 
      REQUIRED. If that is impossible for you, call the Associate Superintendent, Mr. Perkins B. Pringle at 
      330.376.4915.

21. How did you learn about the Ida B. Wells Community Academy #2? _____________________________________

_________________________________________________________________________________________________

22. Would you like to learn more about the Ida B. Wells Community Academy #2? If you are connected to the Internet, read the Ida B. Wells Community Academy's Statement of Principles "On These Principles We Stand." 

For More Information and to Receive Additional Registration Forms

Call: 330.733.0999  OR  330.376.4915

Send e-Mail to:  Academy@concentric.net  OR  hierogfx@hierographics.org

You may also return this form by FAX to 330.376.4912

Visit the Academy Web Site at http://hierographics.org/AcademyIndex.shtml


*All Information Provided on this Pre-Registration Form is confidential. No information provided will be used for purposes other than the pre-registration of your child.

We are an equal education and employment opportunity institution.


PRE-REGISTRATION FORM  (Revised December 22, 2000)