623 Grand Avenue
Laurel Springs, NJ 08021
To be completed by the parent or legal guardian:
Name of Student Applicant: ____________________________________________________
Street Address: ______________________________________________________________
City: _____________________ County: _____________________ Zip: _________________
Birth date: __________________________
Home Phone Number: ________________ Parent /Guardian’s Work Phone: _____________
District of Residence: __________________________________________________________
School of Residence: ___________________________________________________________
Applying for admission to Grade Level _________________ in 2012-2013
Does the student have a current IEP? _______ If yes, attach a copy.
Does the student have a 504 Plan? _______ If yes, attach a copy.
Any student applying for the (Name of School) School Choice Program will be conditionally accepted pending educational program review, annual IEP review or re-evaluation, or 504 plan review during or at the end of the current school year.
If the district of residence has provided written notification that the student may participate in the school choice program, please attach the notification to this application.
______ If notification has not been received from the district of residence check here.
Falsifying any information on this application will result in the
denial of the student’s participation in the Choice Program.
By my signature I certify that:
I am applying for the student’s admission to (Name of School) District for academic reasons only and not for athletic, extracurricular, or social reasons; and that a Notice Of Intent To Participate In The School Choice Program was provided to the district of residence. I also certify my child will be enrolled in my resident school district for the entire 2011-2012 school year.
Signature of Parent or Guardian Name of Parent or Guardian
DATE: _______________________