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<br />o CHECK HERE IF <br />APPLICATION IS <br />TO BE INCLUDED <br />IN THE LOTTERY <br />EACH YEAR <br />UNTIL ENROLLED <br /> <br />~ <br />aQ.~'Sc~ool <br />Enrollment AppIication/Lottery Form 0 <br /> <br />(Complete O~e Form Per Child) <br /> <br />Please Complete All Information Requested Below <br /> <br /> <br />g< L <br /> <br />I <br /> <br />District #4008 <br /> <br />Student Name <br /> <br />CHECK HERE <br />IF A smLING <br />CURRENTLY . <br />ATTENDS PACT <br /> <br />Last <br /> <br />First <br /> <br />Middle <br /> <br />Gender: D M D F <br /> <br />Student Address <br /> <br />Apt# <br /> <br />City/State Zip PO Box <br />Resident School Dist. # <br />(Determined by Residence) <br /> <br />a For Kindergarten Year 20~ - 20~ <br />Preference (Not Guaranteed): a AM a PM <br />Title (Services? 0 Yes, 0 No <br /> <br />Current School Dist. # <br /> <br />Telephone (_) <br /> <br />a Yes a No If Yes, Dist. # ---.:.... <br />Spouse Information <br /> <br />street <br />S~udent ~/_/_ <br />Birthdate ' Mo Day Year <br /> <br />Current School Year 20~-20_ <br /> <br />Home Phone (___) <br /> <br />Grade __ <br /> <br />Student's SSN (Optional): _ _ _ _ _ _._ _ _ _ <br /> <br />Current School * <br />Address <br /> <br />* .' . . . '. . .., <br />If Private or Home Scl!ool" has student EVER attended a MN Public School? <br />Head of Household Information <br /> <br />Name <br />Address/Phone <br />Employer's Name/Phone <br /> <br />'Name <br />AddresS/Phone <br />Employer's ,Name/Phone <br /> <br />. ':~it1t..tiiif'" <br /> <br /> <br />.. .~~~1~rii';~f"cfiJi~~~!~;,~~~jj <br /> <br />· Minnesota Statutes require the school district to keep accurate and updated personal records (or all pupils. This information will <br />become part of the studenfs 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 currentstudents 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, MN55303 Parent I Guardian Signature Date <br /> <br />Date Rec'd: <br /> <br />OFFICE USE ONLY <br />Lottery Date: <br /> <br />D SIB Sta~: <br /> <br />Enn Date: <br /> <br />Resident Dist #: <br /> <br />Stu ID#: <br /> <br />LLA Code: Transportation Code Advisor: <br />The following information is needed in order for the school to provide any ~ecessary addi~ional 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? 0 Ye~, '0 No.lf yes, please explain on reverse. <br />Does student have a disability that requires an accommodation?' a Yes CJ No If yes, please describe on reverse. <br /> <br />What language(s} do family members in your home use ".'hen speaking to each other? 0 English 0 Other <br />Please check ONE category that BEST describes the studenfs racial/ethnic background: <br />~-Amerjcan Indian CJ Asian or Pacific Islander' D Black aWhite a Hispanic DOther <br /> <br />-169- <br />