The Ida B. Wells Community Academy

Sponsored by the Ohio State Department of Education and
the Ida B. Wells Community Academy, Inc., in association with the 
Task Force for Quality Education and other Community Organizations. 

(Please Print or Type Your Responses to Each Item)

RETURN APPLICATION TO:  670 Wooster Avenue, Akron, Ohio   44307-1868 
ATTN: Mr. Perkins B. Pringle    Phone:  330.376.4915  OR   FAX:  330.376.4912 

 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 if they live outside the Akron Public School District. 
     Should you be interested or know someone who is interested in doing so, contact Dr. Edward W. Crosby at 
     330.673.9271  OR   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 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's Advisory Board or Site-Based 
     Management Committee, if your child(ren) is(are) enrolled? Yes ______ No ______

17. Provide a brief statement describing your reasons for having your child(ren) attend a public Community School 
     sponsored by Ida B. Wells Community Academy and the Ohio Board of Education in association with a number 
     of Akron's community organizations. (If you need more space, add additional sheets of paper.)





18. Do you know any parents who would consider enrolling their child(ren) in the Ida B. Wells Community Academy? 
     Yes ______ No ______ If yes, would you, please, instruct them to write or call for a registration Application.

19. Can you provide transportation for your child(ren) if they missed the school bus? Yes ______   No ______ 
      (Not required for your child(ren) to attend the Academy.)

20.  Parent participation in the Governance and Planning of the Ida B. Wells Community Academy's operation and 
      decision making process is requested so that you will have first hand knowledge of and can participate in all 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 
      educational process and practices? Yes _______ No _______ Your participation is REQUIRED. If that is 
      impossible for you, contact the Principal, Mr. Perkins Pringle at either of the numbers below.

21. How did you learn about the Ida B. Wells Community Academy? ________________________________________


22. Would you like to learn more about the Ida B. Wells Community Academy? If so, read the Academy's Mission
     Statement "Serving the Educational Needs of the People." 

For More Information and to Receive Additional Registration Forms

Call:  330.376.4915  OR  Send e-Mail to:  OR

*All Information Provided on this Registration Application Is confidential. No information provided will be used for purposes other than the enrollment of your child.

We Are An Equal Education and Employment Opportunity Institution.

REGISTRATION APPLICATION 02 (Revised October 21, 2000)