EmailMe Form - Independence Charter School West

Thank you for your interest in Independence Charter School West. To apply for a student entering grades K-3, please fill out this form and submit no later than February 1. Submit one form for each child. A public lottery will take place February 16th in order to determine admission.

Student Information

Student Name *

First Middle Last

Student's Address *

Street Address (no PO Boxes), City

Birth Date *

MM / DD / YYYY

Current Age *

Current Grade *

If child is currently in school/preschool/daycare, name of current school:

Grade Entering in Fall 2016 *

*Note that all incoming Kindergarten students must be 5 years old by September 1, 2016. No exceptions

The neighborhood HS at student's primary address. (If unsure please check the SchoolFinder on the School District's website.) Lottery priority goes to Bartram, Overbrook and Sayre.

School Finder: https://webapps.philasd.org/school_finder/ *

Bartram High School

Overbrook High School

Sayre High School

Other

If "Other" please specify below

Other Neighborhood HS

Family Information

*Please list full name of a parent/guardian with whom child lives during the school year.

Parent/Guardian #1 Name *

First Last

Email

Please print clearly

Preferred Phone # *

### - ### - ####

Parent/Guardian #2 Name

First Last

Email

Please print clearly

Preferred Phone #

### - ### - ####

*Does this child have siblings in the same household for whom you are submitting a separate ICS-West application for this school year? If yes, note their names and grades they will be entering.

*

The Information in this application is correct to the best of my knowledge.

*

If selected in the lottery, I will provide proof of residency and proof of child’s age for registration.

Name *

First Last

Name of person completing the form.

Date *

MM / DD / YYYY

Date of form completion.

Email *

Confirmation will be emailed to this address.

Independence Charter School-West is a tuition-free pubic school. Admission, the provision of services, and referrals of students shall be made without regard to race, color, religious creed, disability, sexual orientation and gender identity, ancestry, national origin (including limited English proficiency), or age.