Green Dot New York Charter School** 2013-2014 Application for Entering 9th Grade Students

Green Dot New York Charter School, founded in partnership with the United Federation of Teachers, is now accepting student applications. This public high school is providing a comprehensive college-preparatory education. Located on the fourth floor of 600 St. Anns Avenue Bronx, NY 10455 (in the IS 162 Building), the school will accept 110 9th grade students for the 2013-2014 school year. Current 8th grade students may apply. STUDENTS SHOULD APPLY TO GREEN DOT NEW YORK CHARTER SCHOOL IF THEY WISH TO ATTEND GREEN DOT NEW YORK CHARTER SCHOOL RATHER THAN A DEPARTMENT OF EDUCATION HIGH SCHOOL. Application Deadline: April 1, 2013

Mail or Deliver Applications to: Green Dot New York Charter School Attn: Student Application 600 St. Anns Avenue Fourth Floor Bronx, NY 10455 Lottery: If the number of applications exceeds capacity, students will be selected by lottery after the due date of the application. Preference is given to students residing in Community School District #7. Students not accepted for admission will be placed on a waitlist in the order determined by the lottery. The lottery will be on April 2, 2013 at the school at 5:30pm. Enrollment: All accepted students must complete the schools enrollment process. Failure to complete this process may forfeit acceptance to the school. Students must also complete our Summer Bridge program in July and August. Among required enrollment forms, families must present documentation that their child has received all vaccinations. Green Dot New York Charter School does not discriminate against any student on the basis of race, ethnicity, national origin, gender, or disability or for any other basis that would be unlawful for a public school. For additional information, please call 718-292-6543 or 718-585-0560 between 8:30am and 4pm or write to akapadia@greendotny.org or visit www.greendot.org/newyork.
____________________________________________________________________________________________ **Please note that the schools name will change during the 2012-2013 school year.

Green Dot New York Charter School Application to the 9th Grade for the 2013-2014 School Year
(Please complete one application per child) *denotes required STUDENT INFORMATION *STUDENTS NAME: _________________________________________________________________________________ *STUDENTS DATE OF BIRTH: _________________________________ *STUDENTS GENDER (CIRCLE ONE): MALE FEMALE

*CURRENT SCHOOL: ________________________________________________________________________________ *CURRENT SCHOOL ADDRESS: ________________________________________________________________________ PARENTS/GUARDIANS INFORMATION *PARENTS/GUARDIANS NAMES: ______________________________________________________________________ *RELATIONSHIP TO STUDENT: ________________________________________________________________________ *ADDRESS: ___________________________________________________________________________________ (STREET) (APT.) ___________________________________________________________________________________ (CITY) (ZIP CODE)

*HOME TELEPHONE: __________________________________ WORK TELEPHONE: __________________________________ *MOBILE TELEPHONE: _________________________________ EMAIL: ____________________________________________ ADDITIONAL INFORMATION *DATE OF APPLICATION (TODAYS DATE):_______________________________________________________________ *NAME OF SIBLINGS ALSO APPLYING TO OR ATTENDING THE GREEN DOT NEW YORK CHARTER SCHOOL: _________________________________________________________________________________________________ OPTIONALSTUDENT IS IN SPECIAL EDUCATION OR HAS AN IEP (CIRCLE ONE): YES NO YES NO

OPTIONALSTUDENT IS IN ENGLISH AS A SECOND LANGUAGE CLASSES OR BILINGUAL CLASSES (CIRCLE ONE): I have read and understand the terms of this application, including the requirement of Summer Bridge. ___________________________________________________________ *PARENT/GUARDIANS SIGNATURE

Non-Discrimination Statement: A charter school shall not discriminate against or limit the admission of any student on any unlawful basis, including on the basis of ethnicity, national origin, gender, disability, intellectual ability, measures of achievement or aptitude, athletic ability, race, creed, national origin, religion or ancestry. A school may not require any action by a student or family (such as an admissions test, interview, essay, attendance at an information session, etc.) in order for an applicant to either receive or submit an application for admission to that school. FOR OFFICIAL USE ONLY RECEIVED ON: _______ RECEIVED BY: _______ LOTTERY NUMBER: _______ OF _______

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