New York State Charter School Uniform Application Form Estado de Nueva York Formulario Unico de Solicitud Applicable School Year: 2015-2016 Ano Escolar: Name of Charter School: PUC Achieve Charter School Nombre de Escuela Charter: Contact Info for Charter School: 14 Mark Street Rochester, NY 14605 Contacto para la Escuela: Application Deadline: Tuesday, March 31, 2015 Fecha tope para solicitud: Lottery Date and Location (if known): 6:00 PM Wednesday April 1, 2015 Location: PUC Achieve – Lugar a la ecuela Fecha y lugar de loteria: Directions for Submission of Applications: Instrucciones para entrega de la solicitud: The completed application may be either given directly to an employee of PUC Achieve or PUC National or sent via US Mail, email to [email protected] or call (585)471-6219 La solicitud completada tiene que entregarse a un empleado de PUC Achieve of PUC Nacional o por correo, email to [email protected] or call(585)471-6219 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. Declaración de No Discriminación: Una escuela charter no discriminara la admisión de ningún alumno a base de etnicidad, origen, genero, falta de habilidad alguna o intelecto, aptitud ni habilidad atlética, raza, religión. La escuela no puede requerir ninguna acción de parte del alumno o padre (como examen de admisión, entrevista, escribir algo, etc.) en orden para que el alumno pueda aplicar para admisión. Note: A separate application must be completed and submitted for each child applying for admission. Se tiene que llenar una solicitud separada por cada alumno. Page 1 of 2 School Site 14 Mark St Rochester, NY 14605  585.471.6219  FAX 585.232.1316  www.pucschools.org Applicant Student Information / Información del Alumno que Aplica: 1.* Name (First, Last): *Nombre (primero, apellido): 2.* Date of Birth (MM/DD/YYYY): *Fecha de nacimiento (mm/dd/yyyy): 3.* Gender (circle one): *Genero (circule uno): 4.* Home Address (street address, city, state, zip code): *Direcion (calle, cuidad, estado, codigo postal): Male / Female Hombre / Mujer 5.* School District (or New York City Community School District), if known: *Distrito Escolar: 6.* Grade Applying for: *Grado al cual aplica: 7.* Does the applicant student have a sibling(s) who is currently enrolled in this charter school? (circle one). If yes, list at least one sibling’s name, current grade and date of birth. *El aplicante tiene un hermano(a) en la escuela? (circule uno) Escriba el nombre del hermano, el grado y su fecha de nacimiento. Yes / No Parent/Guardian Information / Informacion del Padre/Madre o Guardian: 1.* Name (First, Last): Nombre (primero, apellido): 2.* Relationship to Student: Relacion con el alumno: 3. Home Address (street address, city, state, zip code): Direcion (calle, cuidad, estado, codigo postal): 4. * Phone Number(s), if available: Numero telefonico: 5. Email Address(es): Correo electronico: Parent/Guardian Signature/Firma: __________________________________ Date/Fecha:_________________ * The items marked with an asterisk (*) are the only items that may be required in order to apply to this charter school. Any items not marked by an (*) are optional. Las cosas marcadas con * son opcionales. Page 2 of 2 School Site 14 Mark St Rochester, NY 14605  585.471.6219  FAX 585.232.1316  www.pucschools.org