1. Name: _________________________________________________ Date: ________________________ 2. Home Address: _______________________________________________________________________
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.
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
17. Provide a brief statement describing your reasons for having your
child(ren) attend a public Community School
_________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ 18. Do you know any parents who would consider enrolling their child(ren)
in the Ida B. Wells Community Academy?
19. Can you provide transportation for your child(ren) if they missed
the school bus? Yes ______ No ______
20. Parent participation in the Governance and Planning of the
Ida B. Wells Community Academy's operation and
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
For More Information and to Receive Additional Registration Forms Call: 330.376.4915 OR Send e-Mail to: Academy@concentric.net OR hierogfx@hierographics.org
We Are An Equal Education and Employment Opportunity Institution.
REGISTRATION APPLICATION 02 (Revised October 21, 2000) |