Certificate of Legal Guardianship - DOC by pit69552

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									                              CITY CHARTER HIGH SCHOOL
                                                         2010-2011
   Dear Parent or Guardian:
   Thank you for your interest in City High!

   You need to provide us with these documents listed below in order to complete the
   enrollment process of your child.


           __ ** First Proof of residency
              (Driver’s license, State ID, Voter Registration Card)

           __ **Second proof or residency
              (Utility Bill, Mortgage Deed/Lease)

            __ Your child’s Birth certificate

            __ LEGAL GUARDIANSHIP DOCUMENTS (If you are not the
            child’s biological parents)

            __ IEP (Special Education) RECORDS FOR YOU CHILD

            __ LAST 8th grade REPORT CARD (When you receive it in June 2008)

**Note
Any documents forwarded as proof of residency must have your CURRENT address.
School district residency is based on the parent/guardian address.

Please mail the completed package to:

                                     City Charter High School
                                      The New Clark Building
                                    717 Liberty Avenue, 9th Floor
                                        Pittsburgh, PA 15222




   Page 1 of Charter School Student Enrollment Form                                                               PDE 7/2002
   Instructions for this form can be found at www.pde.state.pa.us. Under the K-12 Schools folder, click on Public Schools, then
   Charter School, then Reporting.
             CHARTER SCHOOL STUDENT ENROLLMENT NOTIFICATION FORM
                            For School Year 2010-2011


              City Charter High School, 717 Liberty Avenue, Pittsburgh, PA 15222
                    Charter School Contact Person: Dr. Richard Wertheimer
     Telephone: 412.690.2489            Fax: 412.690.2316       e-mail address: wertheimer@cityhigh.org




I. Student Information:

Last Name: ___________________________ First Name: __________________________ MI:_____

Home Address: ____________________________________________________________________

City/State/Zip: ____________________________________________ Telephone: (___)___________

County: _________________________________________________

Mailing Address (if different from Home Address): _________________________________________

City/State/Zip: ______________________________________________________________

Date of Birth: ______________ Age: _____            Race: ________



II. School District of Residence and Former School Information:

School District of Residence (ex. Pittsburgh Public, Shaler Area etc.)

_____________________________________

Current School Information (other than pre-school):

__ Public School __ Charter School __ Home School __ Nonpublic School

__ Student Not Enrolled in School Preceding Enrollment in Charter School Because:

        __ Entering Kindergarten __ Re-enrolling Dropout __ Other __________________________

Name of Current School: __________________________________________________________

Address of Current School: ________________________________________________________

Current Grade: ____ Withdrawal Date from Current School: ___________________

Was your child receiving special education services based on an IEP? _____Yes _____No

        If yes, do you have the child’s special education records (IEP)? _____Yes _____No




Page 2 of Charter School Student Enrollment Notification Form                                   PDE 7/2002
III. Parent/Guardian Information:

Child Lives With: __ Both Parents __ Both Parents Alternately __ Mother Only __ Father Only
        __ Legal Guardian __ Foster Parents __ Other Adult _________________________
       Special custodial court instructions: __ Yes __ No (If yes, please provide a copy of court order)
     _________________________________________________________________________________

Complete parent/guardian name and address information as applicable

Father’s Name: _______________________________________________________________

Address: ____________________________________________________________________

City/State/Zip: ________________________________________________________________

Home Telephone: (___)__________________             Work Telephone: (___)_______________

Cell Phone: (___)________________              E-mail __________________________________________


Mother’s Name: _______________________________________________________________

Address: _____________________________________________________________________

City/State/Zip: ________________________________________________________________

Home Telephone: (___)___________________                        Work Telephone: (___)_______________

Cell Phone: (___)________________             E-mail______________________________________________

(If the student is not living with parents, please complete this section.)
__ Guardian               __ Foster Parent           __ Other Adult Name
Name: _____________________________________________________________________
Address: ____________________________________________________________________
City/State/Zip: ________________________________________________________________
Home Telephone: (___)_______________ Work Telephone: (___)_______________Cell Ph:_______________
My signature on this form indicates my decision to have my child attend the charter school named on page 1 of
this form and signifies my request that appropriate school records be forwarded from the school district to the
charter school. My signature also certifies that my child is not, and will not be, enrolled in another public school,
a nonpublic school or a private school at the same time he or she is enrolled in this Charter School.


Signature of Parent/Guardian: ________________________ Date: ____________
IV. To be completed by Charter School:

Verification of date of birth: __ Birth Certificate __ Other: _______________________________

Proof of residency: __ Mortgage Statement __ Lease __ Utility Bill __ Other _______________________

Official Enrollment Date: _______________ Anticipated Date of First Attendance: 8-30-2010

Grade Student is Entering: _______

Signature of Charter School Representative: __________________________________________________



Page 2 of Charter School Student Enrollment Notification Form                                            PDE 7/2002

								
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