Kent Innovation High A Project Based Learning School Application for 2015-16 Fall Enrollment (District Enrollment Deadline is 03/27/15) ~ Please Print ~ Student Name: Preferred Name: Address: City/Zip: Student Birth Date: Gender: Student will enroll in: School District student lives in: Father’s Name: 9th grade 10th grade M F Current school: Name of high school where student will take elective classes? (Communication is done almost exclusively by email) Father’s Email: Address City/Zip Home Phone: Cell Phone: Work Phone: Step-Mother’s Name (if applicable): Mother’s Name: (Communication is done almost exclusively by email) Mother’s Email: Address City/Zip Home Phone: Cell Phone: Work Phone: Step-Father’s Name (if applicable): Guardian’s Name: Guardian’s Email: Address City/Zip Home Phone: Cell Phone: Work Phone: Caseworker Contact (if applicable): Student Resides with: ___Birth Parents ___Single birth mother ___Single birth father ___Foster Parent(s) ___Birth father and step-mother ___Birth mother and step-father ___Other___________________________________ Student is: (Circle) American Indian Asian Black/African American Native Hawaiian/Other Pacific Islander Primary Language Spoken at Home: Does your student have an IEP? If yes, details: White/Caucasian ELL services received? Y N Hispanic/Latino Y N Does your student have a 504 plan? If yes, details: (in order to accommodate your student, please share a copy of the IEP with KIH) Y N (in order to accommodate your student, please share a copy of the 504 plan with KIH) Name of most current/recently completed math class: Pre-Algebra Geometry Algebra I Algebra II Letter Grade Earned by Student: Other:__________ Name of most current/recently completed English class: English 8 English 9 English 10 English 11 Letter Grade Earned by Student: Other:__________ Name of most current/recently completed science class: Earth Science Biology Chemistry Physics Letter Grade Earned by Student: Other:__________ Name of most current/recently completed social studies class: US History World History American History Civics/Econ Letter Grade Earned by Student: Other:__________ Student is successfully passing all classes: Y N If no, details: Student to be considered for: _____Fall Enrollment (September 2015) _____Semester Enrollment (January 2016) MANDATORY student and family tour of KIH completed: ___Yes ___No _____Not yet, but will be scheduled. Upon acceptance, student is issued a t-shirt. Please indicate unisex adult size: XS S M L XL 2X 3X 4X DISTRICT GUIDANCE OFFICE: Application approved? Y N Wait List ? Y N __________________________________________________________________________________________________ Guidance Counselor/School Official Signature Date Please return completed applications to: 363-8030 FAX ~or~ [email protected] NOTE: Student is not officially enrolled until Kent Innovation High notifies you in writing.