Kent Innovation High
A Project Based Learning School
Application for 2015-16 2nd Semester
(District Enrollment Deadline is 01/06/16)
~ Please Print ~
Student Name:
Preferred Name:
Address:
City/Zip:
Student Birth Date:
Gender:
Student will enroll in: 9th grade 10th grade 11th grade
Current school:
School District
student lives in:
Father’s Name:
M
F
Name of high school where student will take elective
classes?
(Communication is done almost exclusively by email)
Father’s Email:
Address
City/Zip
Home Phone:
Cell Phone:
Work Phone:
Step-Mother’s Name (if applicable):
Mother’s Name:
(Communication is done almost exclusively by email)
Mother’s Email:
Address
City/Zip
Home Phone:
Cell Phone:
Work Phone:
Step-Father’s Name (if applicable):
Guardian’s Name:
Guardian’s Email:
Address
City/Zip
Home Phone:
Cell Phone:
Work Phone:
Caseworker Contact (if applicable):
Student Resides with:
___Birth Parents ___Single birth mother ___Single birth father ___Foster Parent(s)
___Birth father and step-mother ___Birth mother and step-father ___Other___________________________________
Student is:
(Circle)
American Indian
Asian
Black/African American
Native Hawaiian/Other Pacific Islander
White/Caucasian
Primary Language Spoken at Home:
Does your student have an IEP?
If yes, details:
ELL services received?
Y
Hispanic/Latino
N
Y
N
Does your student have a 504 plan?
If yes, details:
(in order to accommodate your student, please share a
copy of the IEP with KIH)
Y
N
(in order to accommodate your student, please share a copy
of the 504 plan with KIH)
Name of most current/recently completed math class:
Pre-Algebra
Geometry
Algebra I
Algebra II
Letter Grade Earned by Student:
Other:__________
Name of most current/recently completed English class:
English 8
English 9
English 10
English 11
Letter Grade Earned by Student:
Other:__________
Name of most current/recently completed science class:
Earth Science
Biology
Chemistry
Physics
Letter Grade Earned by Student:
Other:__________
Name of most current/recently completed social studies
class:
US History
World History
American History Civics/Econ
Letter Grade Earned by Student:
Other:__________
Student is successfully passing all classes:
Y
N
If no, details:
Student to be considered for: _____Fall Enrollment (September 2015)
_____Semester Enrollment (January 2016)
MANDATORY student and family tour of KIH completed: ___Yes ___No
_____Not yet, but will be scheduled.
Upon acceptance, student is issued a t-shirt. Please indicate unisex adult size: XS S M L XL 2X 3X 4X
DISTRICT GUIDANCE OFFICE:
Application approved? Y
N
Wait List ? Y N
__________________________________________________________________________________________________
Guidance Counselor/School Official Signature
Date
Please return completed applications to: 363-8030 FAX ~or~ traceyferguson@kentisd.org
NOTE: Student is not officially enrolled until Kent Innovation High notifies you in writing.