GOLDEN DOOR CHARTER SCHOOL

180 Ninth Street

Jersey City, New Jersey 07302

Tel. 201-795-4400 Fax 201-795-3308

REQUEST TO ATTEND

2008-2009

You only need to fill out one form per family, list additional children under siblings.

Please print.

Student’s Full Name_________________________________________________________________________________________________

Mailing Address____________________________________________________________________________________________________

Street P.O. Box

____________________________________________________________________________________________________

City or Town State Zip Code

Date of Birth__________________________ Student’s Grade for 2008-2009 School Year __________________________________

(month/day/year) *Kindergartener’s Must Be 5 Yrs. Old on or Before September 30^th.

SIBLINGS Please list all siblings from the same household that you would like to attend The Golden Door Charter School (use other side of this form to list names that do not fit in the spaces provided below.)

________________________________________________________________________________________________/_______/_________

First Name Last Name Grade for 2008-2009 Date of Birth

School Year (month/day/year)

_______________________________________________________________________________________________/_____/____________

First Name Last Name Grade for 2008-2009 Date of Birth

School Year (month/day/year)

As mandated by our charter, we are able to give preference to siblings in the event that a lottery is required. Please indicate which method you would like children in your household entered into the lottery if this situation arises.

____ Please enter each child individually. I know that not all are guaranteed acceptance if one or more is chosen through the random selection process.

____ Please enter all children in my household under one name. I know that either all or none of them will be chosen through the random selection process.

Mother/Guardian’s Full Name:________________________________________________________________________________________

Address (if different_________________________________________________________________________________________________

from student’s) Street P.O. Box City/Town State Zip Code

Father/Guardian’s Full Name:_________________________________________________________________________________________

Address (if different_________________________________________________________________________________________________

from student’s) Street P.O. Box City/Town State Zip Code

Mother’s Home Number ( )_____________________ Father’s Home Number ( )____________________

Work Number ( )____________________ext______ Work Number ( )___________________ext_____

Golden Door Charter School

Request to Attend Form

Page Two

Education Information

School Attended 2007-2008______________________________________

Address: ______________________________________________________________________________________

Street City or Town State Zip Code

Reason for transfer?________________________________________________________________________________

______________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________

Acceptance Procedure - Lottery Notice

Due to limited availability in Golden Door, all Request To Attend forms are put into a lottery selection process. DEPENDING on the number of seats that MAY or MAY NOT be available in any particular grade, your child may or may not be placed. For example: if your child has applied for a seat in the 2^nd grade and he/she is selected number 1in the drawing, IF there is a seat available, then he/she may be placed. If a seat is NOT available and he/she is selected number 1in the drawing, he/she will NOT be placed until and if a seat becomes available. Your child will remain on the waiting list until the following year at which time the waiting list DOES NOT rollover, you MUST complete another Request To Attend the following year.

Signed_____________________________________________ Date: ____________________________

Month/Day/Year

Please return this form to Golden Door Charter School, 180 Ninth Street, Jersey City, NJ 07302. Call 201-795-4400 if you have any questions about this form.

For office use only: Date Received:___________________________ Date Accepted:______________________________