UrbanPromise School Application for Enrollment

Student Information

Student Name*

First Middle Last

Expected Grade Level*

Birth Date*

Address*

Street Address Address Line 2 City State ZIP Code

Home Phone*

Sex*

Male

Female

School District student lives in

Brandywine

Colonial

Christina

Red Clay

Present School

Present District

Years Attended

School Address

Street Address Address Line 2 City State ZIP Code

My child is…

NOT Hispanic or Latino

Hispanic or Latino (Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race)

What is your child’s race, select one OR MORE:

American Indian or Alaska Native (A person having origins in any of the original peoples of North and South America who maintains a tribal affiliation or community attachment).

Black or African American (A person having origins in any of the Black racial groups of Africa)

Asian (A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent).

Native Hawaiian or other Pacific Islander (A person having origins in any of the original peoples of Hawaii, Guam, Samoa or other Pacific Islands).

White (A person having origins in any of the original peoples of Europe, the Middle East, or North Africa).

How did you hear about UrbanPromise?

Parent/Guardian Infromation

Mother's Name (or legal guardian):

First Last

Date of Birth

Home Address (if different):

Street Address Address Line 2 City State ZIP Code

Cell Phone

Employer:

Occupation:

Church Membership:

Pastor:

First Last

Father's Name (or legal guardian)

First Last

Date of Birth

Home Address (if different):

Street Address Address Line 2 City State ZIP Code

Cell Phone

Employer:

Occupation:

Church Membership:

Pastor:

First Last

Student Lives With (check all that apply):

Father

Mother

Stepfather

Stepmother

Grandparent

Guardian

Other

Check any that apply:

Father is deceased

Mother is deceased

Parents are seperated

Parents are divorced

Other Children in the Family

Child 1 Name:

First Last

Child 1 Age:

Child 1 School:

Child 2 Name:

First Last

Child 2 Age:

Child 2 School:

Child 3 Name:

First Last

Child 3 Age:

Child 3 School: