Student Information:

First Name
Middle Name
Last Name
Date of birth
Zip Code
Home Phone#
Other Phone#  Describe
Grade Applied For
Current School
Does student have a sibling currently attending this school? Sibling's Name:
Does the student have siblings applying to this school?(If considered, subject to verification) 1.Sibling's Name:
2.Sibling's Name:

Parent/Guardian Information:

First Name
Last Name

We/I, the undersigned, hereby certify that, to the best of our/my knowledge and belief, the answers to the foregoing questions and statements made by us/me in this application are complete and accurate. We/I understand that any false information, omissions, or misrepresentations of facts may result in rejection of this application or future dismissal of the applicant.

NON-DISCRIMINATION STATEMENT: It is the policy of Kenilworth Science and Technology Charter School to comply with all state and federal regulations regarding admission and not to discriminate during the admission and the lottery process on the basis of gender, national origin, ethnicity, religion, disability, academic, artistic, athletic ability, or the district the child would otherwise attend.