APPLICATION FOR NON-RESIDENT NEWCOMB CENTRAL SCHOOL DISTRICT 5535 Rt 28N Newcomb, New York 12852 Superintendent Clark "Skip" Hults [email protected] www.newcombcsd.org 518-582-3341 PERSONAL INFORMATION (Please type or print legibly)

(Full legal Name) Last

Home address

First

Street

E-mail

Nickname

City

Middle Initial

Zip

Date of Birth

Home Telephone Number

Cell Phone Number

FAMILY INFORMATION I live with (check all that apply): Mother Father Stepfather Other, please list (including all brothers and sisters and their ages):

Father (or male guardian): Last Name

First Name

Occupation

Employer

Business Phone

E-mail

Last Name

First Name

Occupation

Employer

Business Phone

E-mail

Mother (or female guardian):

Stepmother

EMERGENCY INFORMATION In case we are not able to contact your parents, please tell us who we can contact.

Name:

Last

First

Home Telephone Number

Relationship:

E-mail:

ACADEMICS

School Name:

Address:

Telephone Number:

Principal/Headmaster:

What type of school do you currently attend:

Public

Private

What grade did you last complete? What do you like about school?

SPECIAL INTERESTS AND ACTIVITIES What, if any, musical instrument(s) do you play? Instrument: ________________________ Since when? ____________ How Often? _____________ Instrument: ________________________ Since when? ____________ How Often? _____________ What sports, if any, do you participate in now? PLEASE NOTE THAT PARTICIPATION IN SPORTS IS NOT GUARANTEED Sport: ________________________ Since when? ____________ How Often? _____________ Sport: ________________________ Since when? ____________ How Often? _____________ Sport: ________________________ Since when? ____________ How Often? _____________ Describe any other interests, hobbies or activities you are involved in: ________________________

Do you have any allergies? Yes treatment used, including medications.

Do you have any health concerns?

No

Yes

If yes, please list below the allergy and any

No

IF yes, please explain below:

Do you have any dietary restrictions (medical, religious, self-imposed)? If yes, please explain:

Yes

No

STATEMENT OF AGREEMENT As a condition of acceptance of a non-resident student, the Parent(s) of such student and the student, as applicable, agree to the following:

1. The Parents shall be responsible for arranging the transportation of the student to and from the District and another adult who shall be responsible for the transportation of the student, if the parent is not available, in the event of early dismissal; 2. Failure to make appropriate arrangements for the transportation of a non-resident student, including on days requiring early dismissal due to emergency or otherwise, may result in the student’s dismissal; 3. Transportation may be provided for non-resident students if and only if existing bus routing is used, and there is sufficient room on the bus. 4. The student shall be subject to the same rules governing student attendance and student discipline as resident students and these rules. 5. Any violations of school rules, including, but not limited to, excessive tardiness, truancy or other infractions that would result in the suspension of a resident student from school, shall constitute a basis for the student’s immediate dismissal; 6. Prior to such dismissal, the District shall provide the Parent with written notice of the basis for its determination and shall request an informal conference with the Superintendent, which shall provide an opportunity for the Parent and student to question complaining witnesses and present their concerns; 7. The decision of the Superintendent shall be final except a parent may appeal such decision to the Board of Education within 30 days of such determination upon written notice with a statement of the reasons for such appeal; 8. A non-resident student dismissed for disciplinary reasons or nonattendance pursuant to this policy shall not be readmitted under this policy; and 9. Extra Curricular Activities - To the extent otherwise eligible, all non-resident students admitted pursuant to this policy shall be allowed to participate in all activities/sporting opportunities to the same extent as resident students of the District, except that the Parents of such students shall be responsible for their transportation from any after school activities to their home.

Tuition Charges $500.00 per year for the first student in the family; $300.00 per year for each additional student; and Up to a maximum of $1,000.00 per year for each family. By our signatures below, we atest that all information has been given to the best of our knowledge and we agree to all the terms and conditions of Newcomb Central School District.

Student Name

Student Signature

Date

Parent/Guardian name

Parent/Guardian Signature

Date

Parent

Parent/Guardian Signature

Date

Steps to Acceptance 1. 2. 3. 4. 5. 6.

Send to school a fully completed and signed application Send a $100 Good Faith Deposit (Fully refundable if the student does not attend) Letter of good standing from current school district Academic, health and immunization records. (Official) Letter of introduction from student and parents Writing Sample

Internal Use Only Student Name Date of Acceptance Amount of Tuition Amount Paid

Date Paid

Letter of Introduction from Prospective Student (Please handwritten Only)

Prospective Student's Writing Sample (Must be at least one page and handwritten) Please write: Four Reasons Why I Would Like to Attend Newcomb Central School District