1. a. Parent's Name: _______________________________________________ Date: _________________

     b. Parent's Signature: ____________________________________________  Date: _________________

 2. Home Address:  _____________________________________________________________________
                                            Street                        City                         State                      Zip

 3. Telephone Numbers (home) __________________________ (work) ___________________________

 4. Please give the name, age, birth date, sex, and social security number of each child you wish to enroll: 

     (1) _________________________ Age ______ Date of Birth ____________ M __ F __ SSN ________________

     (2) _________________________ Age ______ Date of Birth ____________ M __ F __ SSN ________________ 

     (3) _________________________ Age ______ Date of Birth ____________ M __ F __ SSN ________________ 

     (4) _________________________ Age ______ Date of Birth ____________ M __ F __ SSN ________________

     (5) _________________________ Age ______ Date of Birth ____________ M __ F __ SSN ________________

 5. What schools do they attend? 

     (1) ___________________________ (2) ___________________________ (3) ___________________________ 

     (4) ___________________________ (5) ___________________________

 6. What grades are they in? (1) ___________ (2) ___________ (3) ___________ (4) ___________ (5) ___________

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

     ______________________________________________________________________________________________ 

     Why were they retained?  __________________________________________________________________________ 

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

     If yes, when and why? __________________________________________________________________________ 

     ___________________________________________________________________________________________ 

 9. Does your child(ren) have special educational needs? Yes ________ No ________ 

     If yes, explain which child and type of special need: _____________________________________________

     __________________________________________________________________________________________

     __________________________________________________________________________________________

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

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

12. If yes, what program(s)?_________________________________________________________________

      _____________________________________________________________________________________________

13. What was your annual income? $______________________ (Please attach to this registration form your most 
      recent W1040 Tax Form or another document showing your current annual income.)

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, whether your  
      child(ren) is(are) enrolled or not? Yes ________ No ________

17. Provide a brief statement describing your reasons for having your child(ren) attend a public Community School 
      administered by the Ida B. Wells Community Academy and the Ohio Department of Education. (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, copy this form or 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's educational process and practices? Yes ________ No ________

21. Would you like to learn more about the Ida B. Wells Community Academy? If you are connected to the Internet,  
      read the Academy's "Statement of Principles" on the Web site indicated below. If you are not connected to the  
      Internet, request a copy by calling 330.867.1085.