Application for Enrollment
University SchoolEast Tennessee State University68 Martha Culp Dr. PO Box 70632 Johnson City TN 37614APPLICATION FOR ENROLLMENT: 2020-2021Return To: University School ETSU CampusATTN: Dianna ReaEmail: readg1@mail.etsu.eduApplicants MUST be 5 years old by August 15, 2020 to applyApplicants Date of Birth:(mm/dd/yy): FORMTEXT ????? Gender FORMCHECKBOX Male FORMCHECKBOX FemaleCounty of Residence FORMTEXT ????? Current School: FORMTEXT ????? Current Grade Level: FORMDROPDOWN Grade level applying for 2020-2021 at University School: FORMDROPDOWN Applicant Name:Last FORMTEXT ????? First FORMTEXT ????? Middle FORMTEXT ?????Student Address:Street FORMTEXT ????? City FORMTEXT ????? State FORMTEXT ????? Zip Code FORMTEXT ????? Name(s) of Siblings Currently Enrolled at University School: FORMTEXT ?????Mailing Address if different than residence: Street FORMTEXT ????? City FORMTEXT ????? State FORMTEXT ????? Zip Code FORMTEXT ?????IMPORTANT: If your child is currently enrolled in a public school, does he/she have any of the following educational plans. Check the one he/she has: FORMCHECKBOX IEP FORMCHECKBOX 504 FORMCHECKBOX ELP / ESL / ELLEthnic Background (check one) FORMCHECKBOX American Indian or Alaskan Native FORMCHECKBOX Asian FORMCHECKBOX Black or African American FORMCHECKBOX Native Hawaiian or Pacific Islander FORMCHECKBOX Hispanic FORMCHECKBOX White Citizenship (check one): FORMCHECKBOX USA FORMCHECKBOX Other: FORMTEXT ????? If other, list the date the applicant started school in the USA: (mm/dd/yy): FORMTEXT ????? Mothers Maiden Name: FORMTEXT ????? Applicants City of Birth: FORMTEXT ????? Applicants State of Birth: FORMTEXT ????? Applicants County of Birth: FORMTEXT ?????Guardian 1 Name: FORMTEXT ?????Relationship to student: FORMTEXT ?????Address if different than applicants:Street FORMTEXT ????? City FORMTEXT ????? State FORMTEXT ????? Zip Code FORMTEXT ?????Employer: FORMTEXT ?????Email address: FORMTEXT ?????List phone numbers below and check preferred number: FORMCHECKBOX Home Phone: FORMTEXT ????? FORMCHECKBOX Cell Phone: FORMTEXT ????? FORMCHECKBOX Work Phone: FORMTEXT ????? Has custody of student: FORMCHECKBOX Yes FORMCHECKBOX NoLives with student: FORMCHECKBOX Yes FORMCHECKBOX NoReceives Mailings for student: FORMCHECKBOX Yes FORMCHECKBOX NoGuardian 2 Name: FORMTEXT ?????Relationship to student: FORMTEXT ?????Address if different than applicants: Street FORMTEXT ????? City FORMTEXT ????? State FORMTEXT ????? Zip Code FORMTEXT ?????Employer: FORMTEXT ????? Email address: FORMTEXT ?????List phone numbers below and check preferred number: FORMCHECKBOX Home Phone: FORMTEXT ????? FORMCHECKBOX Cell Phone: FORMTEXT ????? FORMCHECKBOX Work Phone: FORMTEXT ????? Has custody of student: FORMCHECKBOX Yes FORMCHECKBOX NoLives with student: FORMCHECKBOX Yes FORMCHECKBOX NoReceives Mailings for student: FORMCHECKBOX Yes FORMCHECKBOX NoParent Signature FORMTEXT ????? Date FORMTEXT ????? (Electronic submission of this form provides an electronic signature which indicates your acceptance of all terms and conditions of application) IT IS THE RESPONSIBILITY OF THE GUARDIAN TO NOTIFY THE SCHOOL OF ANY CHANGES TO THIS APPLICATION. Please make sure all information is correct. Giving incorrect information may result in rejection of the application or withdrawal from school during the year when discovered. Submitting an application does not guarantee enrollment. If and when the applicant can be enrolled, guardians will be notified. The annual drawing is March of each year. Application must be received by February 28th to be included in the lottery. Late applications will not be included in the lottery and will be added to the waiting list in the order they were received. FORMCHECKBOX Submit on Line: Choose Office or File Button. Save and Share/Send as Email Attachment. Email to readg1@etsu.eduETSU and University School are fully in accord with the belief that educational opportunities should be available to all eligible persons without regard to age, sex, color, race, religion, national origin, or disability. ................
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