Coloma Community Schools Phone: 269-468-2424 Fax: 269-468-2440 302 W. St. Joseph Street Coloma, MI 49038 www.ccs.coloma.org
APPLICATION FOR “SCHOOLS OF CHOICE” – SECTION 105c FOR 2017-2018 CHILD'S NAME __________________________________________ DATE OF BIRTH _____________________ ADDRESS __________________________________________ CITY ________________________ ZIP __________ PHONE NUMBER: HOME ___________________________________ CELL _____________________________ GUARDIAN NAME(S) ____________________________________________________________________________ RELATIONSHIP TO APPLICANT: ___________________________________________________________ SCHOOL DISTRICT YOU RESIDE IN _____________________________ GRADE FOR 2017-18 ________ LIST ALL SCHOOLS ATTENDED: PRESENT (16-17) ________________________________________________________________________________ PREVIOUS (15-16) _______________________________________________________________________________ Grades K – 5: Has your child been suspended from school during the past one year? Yes
No
Grades 6 – 12: Has your child been suspended from school in the past two years?
No
Grades K – 12: Has your child ever been expelled from school? Does applicant child live in the same household with any other child(ren) who attended Coloma Schools in 2016-17?
Yes
Yes No Yes
No
If you check Yes, please give the other child(ren)’s name(s) and school name in the space(s) below. Other Students Names
Coloma School Attended in 2016-17
__________________________________
_________________________________
__________________________________
_________________________________
Is this student currently or ever been enrolled in special education classes?
Yes
No
NOTE: Coloma Schools is required to obtain a 105c Special Education Agreement for any Schools of Choice student that resides outside the Berrien County area and is currently receiving special education services from their resident district. If Coloma is unable to obtain this agreement from your childs school district, your child will not be able to attend Coloma Schools under the Schools of Choice program.
IMPORTANT: Please be sure to sign the release for records on the reverse side. School Use Only Student #: _________________________
UIC: ___________________________
DISTRICT #:______________
SED: _____________
TRANSPORTATION to and from school is the responsibility of the parent/guardian. Students late to school will be considered tardy and no early releases will be allowed for transportation reasons. Please include a copy of the latest REPORT CARD or transcript with the application. If you send the original, it will be returned to you. This form is an APPLICATION ONLY. Completion of this form DOES NOT guarantee student will be accepted into the Schools of Choice program. Please state the reason(s) why you would like your child to attend Coloma Community Schools:
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RELEASE OF INFORMATION
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If any of the information provided on this form is found not to be accurate, acceptance of this application is voidable at the option of Coloma Community Schools.
I give permission to the _________________________________________________School District and the (Applicants Current School District(s)) _______________________________________________________ School District to release any information (Applicants Previous School District(s) - if different from above) requested to Coloma Community Schools for _______________________________________. (Name of Applicant)
Return the completed application and requested documentation as soon as possible but no later than August 18, 2017 to: Coloma Community Schools Dena Garland P.O. Box 550 Coloma, MI 49038
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Name of Contact Person (In case of Body Corporate/Company/Society/FII/Trust/AOP/BOI etc). Address of Sole/First Applicant (Local Indian address only). City: Pin: Dist: State: Send me a pin for Internet services. Telephone: STD Code: Off.: Res.: Fax:
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in United States. Colorado law requires that household good movers must obtain a permit from the Public Utilities. Commission (PUC) prior to beginning service.
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secPon where BOTH referring and referred members must list informaPon to verify the reference. Rebates will be. issued once referring and referred members ...
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