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225.774.1311

8600 Elm Grove Garden Drive

Baton Rouge, LA 70807

07:30 - 19:00

Monday to Friday

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123 456 789

info@example.com

Goldsmith Hall

New York, NY 90210

07:30 - 19:00

Monday to Friday

Student Application

J.K. Haynes Elementary Charter Schools, Inc.

8600 Elm Grove Garden Drive Baton Rouge, LA 70807
Kindergarten – 6th Grade

STUDENT APPLICATION

Applicant's (student) Name: Social Security#:

Address: Phone Number:

City: State: Zip Code:

Has this child ever attended school of any kind?: YesNo
If yes, where?: If yes, when?:

Does child receive Special Education Services?: YesNo
If yes, what type of service does child receive?:

Does child require special accommodations (medication, ADHD, Diabetes, etc.): YesNo
If yes, please explain:

Does Child currently receive free and reduced lunch at school?: YesNo

Family Information

Father's Name: Date of Birth:
Present Address: Phone Number:
Occupation: Work Phone Number:
Education: Email Address:

Mother's Name: Date of Birth:
Present Address: Phone Number:
Occupation: Work Phone Number:
Education: Email Address:

Is student living with the parents? YesNo
If no, name of person(s) with whom student lives:
Relationship to child: Legal Guardian: YesNo
Present Address: Phone Number:
Occupation: Work Phone Number:
Education: Email Address:

Name of Other Children in Home Male or Female Date of Birth School Attending Grade Level
MaleFemale
MaleFemale
MaleFemale
MaleFemale
MaleFemale

Language spoken at home other than English:

Family Doctor:
Address: Phone Number:

Emergency Contacts Name:

Emergency Contact Name (1): Relationship:
Address: Phone Number:

Emergency Contact Name (2): Relationship:
Address: Phone Number:

Does child have an allergy?: YesNo If yes, please explain:

I certify that the facts contained in this application are true and complete to the best of my knowledge. I understand that any misrepresentation of falsification of information or significant omissions may result in this application being rejected. By submitting this form electronically I certify I am the child's parent or legal guardian and have the legal authority to submit this application.

Parent's/Guardian's Information
Name: Email: Phone: