Submit Application

Completion of this form allows the child/children listed to participate in the enrollment lottery which takes place each spring. Your child will be placed in one of three lottery pools. Each pool has a priority. The priority of the pools is as follows: (1st) Founder Status; (2nd) Siblings; (3rd) Open enrollment. The lottery is held during a public meeting. At the time of the lottery your child/family will be randomly assigned a number.

PARENT OR GUARDIAN NAME(S)

RELATION TO STUDENT(S)

Parent or Guardian Signature

(Your signature indicates that the address below is your legal domicile as verified by request of residency)

Date

Street

APT #

City

Zip

Home Phone

Email

Work Phone

Cell Phone

Students applying for Kindergarten must be 5 on or before September 1st the year they enroll and will be verified by a birth certificate prior to enrollment. List name(s) of students below. (List additional children on the back.)

First Name

M. I.

Last Name

Grade

Fall of

Gender

Male
Female

Date of Birth

Last School Attended

First Name

M. I.

Last Name

Grade

Fall of

Gender

Male
Female

Date of Birth

Last School Attended

First Name

M. I.

Last Name

Grade

Fall of

Gender

Male
Female

Date of Birth

Last School Attended

Have any of the children listed ever been expelled from a public or private school?

Yes
No

please explain*

White Pine Charter School is a public school which does not discriminate against any student, teacher, or employee on the basis of race, color, national and ethnic origin, religion, gender, social or economic status or special needs.

If you have questions please call 522-4432.

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