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Application for Lottery

Instructions: Please enter the required information, then click "Print Form," sign, date and mail or fax to the number below PRIOR to clicking " Submit Form."

Hatikvah International Academy Charter School
PO Box 7312
East Brunswick, NJ 08816
Fax: 732-698-0675
www.hatikvahcharterschool.com
Application for Lottery
K-2nd Grade

Name of Student:
Birth Date:
Grade Currently Attending:
School Currently Attending:
Year Applying for:
Name of Parent/Guardian
Address:
Email Address:
Relationship to Student:
Evening Phone Number:
Day Phone Number:
Emergency Contact:
Emergency Phone:
Please print this form and fax or mail before submitting

If any of this information changes, please note, it is your responsibility to contact the school at www.hatikvahcharterschool.com and update your information. If you have any questions about the lottery, please contact the school.(Kindergarten students must be 5 years by October 31, No Exceptions)

By completing and returning this form to Hatikvah International Academy Charter School, I the parent/guardian, acknowledge my consent for my child’s/children’s name (s) to enter the charter school’s admissions lottery. Upon my child’s acceptance, I will request the release of my child’s records from their current school to Hatikvah International Academy Charter School.

Parent/Guardian Signature: __________________________________________ Date: _____________

FOR OFFICIAL USE ONLY

Date Received: ______________ Next Lottery Date: ___________________

Received by: ________________

Communication:_____________________________________________________________

________________________________________________________________________

Hatikvah International Academy Charter School agrees to serve all students and allow no discrimination based on race, ethnic identity, cultural heritage, intellectual capacity, measures of achievement, status of a handicapped person, language proficiency, religion, or any other practice deemed unethical.

Student Name___________________________ Grade applying for____________________

Date Received: ____/_____/_____ Next Lottery Date: ______/_____/________

Received by: ________________