Math, Science, and Technology Charter School Student Application Form

ALL STUDENTS within District 150 are eligible to apply.
Applications must be received or postmarked by May 7, 2010.
Lottery will be held May 13, 2010.

Questions?
Please call: 309.495.5988
or email: studentapplication AT peoriacharterschools.org

Return applications by submitting this online form or:

Mail
Peoria Charter School Initiative
c/o Heartland Partnership
100 SW Water Street
Peoria, IL 61602

In Person
Heartland Partnership
100 SW Water Street
Peoria, IL 61602

Email
studentapplication AT peoriacharterschools.org

Fax
309.495.5917

Student Information

Legal Name of Student

Last: *

First: *

Middle:

Date of Birth: *

Home Phone: *

ie: 309-555-1212

Gender: *

Grade Level Applying For: *

Ethnicity (optional: check one):

Residential Address of Student (NOTE: no P.O. Boxes)

Street: *

Apt. #:

City: *

State: *

Zip Code: *

ie: 61603

Mailing Address of Student

Check here if same as residential address:

Same as mailing address

Street:

Apt. #:

City:

State:

Zip Code:

Current School Information

Type of School (select one): *

Reason for Not In School / Other:

Name of Current School: *

Street Address: *

City: *

State: *

Zip Code: *

School Phone: *

School Fax:

Parent / Guardian / Sibling Information

Parent / Legal Guardian Information

Parent / Legal Guardian: *

Name: *

Street Address: *

City: *

State: *

Zip Code: *

Home Phone:

Cell Phone:

Work Phone:

Email Address:

Second Contact Person (if unable to reach Parent / Legal Guardian)

Name: *

Relationship to Student: *

Home Phone:

Cell Phone:

Work Phone:

Email Address:

Siblings also applying?: *

In accordance with charter law, if one sibling is selected
via the lottery process, preference will be given to other
siblings who have submitted applications.

Sibling grade level?:

Fifth

Sixth

Seventh

Name of Sibling(s):

Peoria Charter School Initiative

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Math, Science, and Technology Charter School Student Application Form