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<br />Enrollment Application/Lottery Form 0
<br />(Complete One Form Per Child)
<br />Please Complete All Information Requested Below
<br />
<br />
<br />E<L
<br />
<br />o CHECK HERE IF
<br />APPLICATION IS
<br />TO BE INCLUDED
<br />IN THE LOTTERY
<br />EACH YEAR
<br />UNTIL ENROLLED
<br />
<br />Distn'ct #4008
<br />
<br />Student Name
<br />
<br />Last
<br />
<br />First
<br />
<br />Middle
<br />
<br />CHECK HERE
<br />IF A SIBLING
<br />CURRENTLY
<br />ATTENDS PACT
<br />
<br />Gender: 0 M 0 F
<br />
<br />Student Address
<br />
<br />Street
<br />Student _/ _/_
<br />Birthdate Mo Day Year
<br />
<br />Apt#
<br />
<br />Home Phone (__~_)
<br />
<br />City/Slate Zip PO Box
<br />Resident School Dist. #
<br />(Determined by Residence)
<br />
<br />o For Kindergarten Year 20~_ - 20~
<br />Preference (Not Guaranteed): 0 AM 0 PM
<br />Title I Services? 0 Yes 0 No
<br />
<br />Current School Year 20_ - 20__
<br />
<br />Grade
<br />
<br />Student's SSN (Optional):
<br />
<br />- -
<br />---- --- ------
<br />
<br />Current School *
<br />
<br />Current School Dist. #
<br />
<br />Address
<br />
<br />* If Private or Home School, has student EVER attended a MN Public School?
<br />Head of Household Information
<br />
<br />Telephone (_)
<br />
<br />DYes 0 No If Yes, Dist. # ~
<br />Spouse Information
<br />
<br />Name
<br />Address/Phone
<br />Employer's Name/Phone
<br />
<br />Name
<br />Address/Phone
<br />Employer's Name/Phone
<br />
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<br />
<br />. Minnesota Statutes require the school district to keep accurate and updated personal records for all pupils. This information will
<br />become part of the student's permanent cumulative record and will be available to appropriate staff members. Minnesota law also
<br />requires that you provide immunization information to your child's school.
<br />· Minnesota Statutes require that charter schools provide preference to two categories of students (if space is available). The first is
<br />to siblings of current students and the second is preference based on location / distance from PACT Charter School and other
<br />pUblic schools. Please refer to MN Statute 124.D.10 subsection 9 regarding enrollment in charter schools.
<br />o Check here If you feel that you qualify for this provision,
<br />
<br />Return Form To: PACT Charter School, Attn: Enrollment,
<br />7250 East Ramsey Parkway, Ramsey, MN 55303 Parent f Guardian Signature Date
<br />
<br />Resident Oist #:
<br />
<br />OFFICE USE ONLY
<br />Lottery Date:
<br />
<br />o SIB Status:
<br />
<br />Enrt Date:
<br />
<br />Date Rec'd:
<br />
<br />Stu 10#:
<br />
<br />LLA Code: Transportation Code Advisor:
<br />
<br />The following information is needed in order for the school to provide any necessary additional support services
<br />for your child. This portion of the form is to be completed ONLY AFTER the student has been enrolled at PACT
<br />Charter School
<br />Has student received Special Education services of any kind? DYes 0 No If yes, please explain on reverse.
<br />
<br />Does student have a disability that requires an accommodation?' 0 Yes 0 No If yes, please describe on reverse.
<br />
<br />What language(s) do family members in your home use v.:hen speaking to each other? 0 English 0 Other
<br />Please check ONE category that BEST describes the student's racial/ethnic background:
<br />@2-American Indian 0 Asian or Pacific Islander 0 Black 0 White 0 Hispanic 0 Other
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