Application for Admission 2005-2006 You must submit a separate application for each child applying

Office Use Only Enrolled Y N Wait List # ______ Grade _______ Out-of- district _______ Group w/ sibling Y ___N

I. General Information

Today's Date _____________________ Child's Current Grade _______ Grade in the Fall 2005 _______

Child's Name: _______________________________________________________ Gender:     Male     Female
Date of Birth: ____________________________

(mark one) My child lives in the Kahakai School District _______ My child lives out-of-district ________
School your child is currently attending: _____________________________ 

Child's Address: _____________________________________________________________________
City, State, Zip: ______________________________________________________________________
Home Phone: ____________________________________ Cell: _______________________________
Parent's email address: _______________________________________________________________________ 

Parents / Guardians:
Mother
Name: ______________________________ Work phone: __________________ Lives with child?  Y .......N
Father
Name: ______________________________ Work phone: __________________ Lives with child?  Y ........N
Guardian/Other
Name: ______________________________ Work phone: __________________ Lives with child?  Y ........N
Relationship: __________________________________________________________

Brothers and Sisters

Name

Current grade

Current School

Applying to IPCS?

______________________

______________________

______________________

Y     N

______________________

______________________

______________________

Y     N

______________________

______________________

______________________

Y     N

Do you wish to group this student with other siblings for enrollment? (*see below)

Y

N

If yes, please list name(s) of sibling(s).

______________________

______________________

______________________

*Applications are considered on an individual basis. However, if there is a lottery, and you want all of your children accepted or none accepted (either all will be admitted or none will be admitted), you may do so by circling YES above and listing names of your children. If you have questions, call (808)327-6205.

II. School History

To assist us in best meeting the needs of your child, IPCS would appreciate the following information.

Other schools child has attended:

School

City

Grade Levels

____________________________ ___________________ _____________
____________________________ ___________________ _____________
____________________________ ___________________ _____________
III. Special Needs:

Has your child ever been identified as having special learning needs?   Yes       No
Does your child currently have an Individualized Educational Plan (IEP)?   Yes       No
Does your child currently have a 504 plan? Yes       No
Is your child currently receiving any special services in school? (counseling, pull-out class, GT etc)  Yes       No
If yes, what services? _________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________

Does your child currently receive any medications that are administered at school? Yes .........No
Does your child have any medical, learning, physical or other special needs of which we should be aware?
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Is there any other information you think would be helpful for us to have about your child?

___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
If your child is currently receiving meal assistance, circle the one that applies: Free ...........Reduced

Child's primary language: _____________________________ Language spoken most in home _______________

 IV. Social Profile
Please share with us your child's hobbies / talent / sport or special interests.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Thank you for taking the time to fill out this application in its entirety and for making sure that you have supplied all available information. Please read the following release and sign below:

In the event that my child has the opportunity to be enrolled in Innovation Public Charter School (IPCS), I hereby authorize IPCS to request any and all records, data or information determined to be relevant to the education of my child with the Department of Education, any other schools and school systems in which my child has previously been enrolled, and any governmental departments, health or social service providers, or other offices whose activities bear directly on the programs or services with which my child is provided at IPCS.

The information I have provided on this application is true to the best of my knowledge.

Print Name of Student: ___________________________________________________________________

Print Name of Parent/Guardian: ____________________________________________________________

Parent/Guardian Signature: _______________________________________   Date: _____________

PLEASE RETURN COMPLETED APPLICATION TO:

Innovation Public Charter School
Admissions
76-147A Royal Poinciana Drive
Kailua-Kona, HI 96740

If you have any questions, please contact us by phone or e-mail:

Barbara Woerner
(808)327-6205
barbara_woerner@notes.k12.hi.us

**Innovation Public Charter School does not discriminate on the basis of race, color, national origin, creed, sex, ethnicity, sexual orientation, mental or physical disability, age, ancestry, athletic performance, special need, proficiency in the English language, or academic achievement.