2014-2015 Application

To apply to the Surry Village Charter School please complete this application and submit.

Child's First Name *

Child's Middle Name *

Child's Last Name *

Address 1 *

Birthdate *

Place of Birth *

Address 2

Gender *

Male

Female

City *

State *

Zip Code *

Home Phone *

District/Town Name *

Current School *

Grade Entering in 2014-2015 *

If Kindergarten

Half-Day (Free)

Full-Day (Fee: $1770/year)

Is this child currently receiving special education services? *

Yes

No

Is this child currently on a 504? *

Yes

No

Parent 1 Name *

Parent 1 Email Address

Address (if different from above)

City

State

Zip Code

Home Phone

Parent 1 Cell Phone

Parent 2 Name

Parent 2 Email Address

Address (if different from above)

City

State

Zip Code

Home Phone (if different from above)

Parent 2 Cell Phone

Is this child the sibling of a current student? *

Yes

No

Please list all siblings applying.

Statement of interest;
Please briefly describe your interest in the Surry Village Charter School. *

How did you find out about the school? *

New Hampshire’s Statutes and Rules require that a school district keep accurate records and

updated personal files for all pupils. This information will become part of the student's permanent

cumulative record and will be available to appropriate staff members and child’s parents. New

Hampshire law requires that you provide Immunization information to your child's school.

By submitting this form, I agree that the above information is correct, I understand that this application does not guarantee a position for my child at the Surry Village Charter School. I attest that I am the legal guardian for this child and if my child is able to attend SVCS, I will participate in the SVCS plan for academic expectations and parent involvement. I agree to allow SVCS to receive my child’s student records from the sending school district if he/she is enrolled.

Kindergarten	1st
2nd	3rd
4th	5th
6th	7th
8th