East Tennessee State University



University SchoolEast Tennessee State UniversityJohnson City, TennesseeAPPLICATION FOR PUPIL ENROLLMENT**Kindergarteners must be 5yrs of age by August 15, 2018 to apply.**Applicants Grade Level Applying for the 2018-2019 School Year FORMDROPDOWN Student Name Last FORMTEXT ????? First FORMTEXT ????? Middle FORMTEXT ????? Male FORMCHECKBOX Female FORMCHECKBOX Social Security Number FORMTEXT ????? Washington County Resident FORMDROPDOWN IEP: FORMDROPDOWN 504: FORMDROPDOWN Student Address: Street FORMTEXT ????? City FORMTEXT ????? State FORMTEXT ????? Zip Code FORMTEXT ?????Birth Date (mm/dd/yy) FORMTEXT ????? U.S. Citizen: FORMDROPDOWN If No, date entered the country FORMTEXT ?????Name(s) of Siblings Currently Enrolled at University School FORMTEXT ?????Name of School Presently Enrolled FORMTEXT ?????Ethnic Background: FORMDROPDOWN Language Spoken by Student FORMTEXT ????? Language Spoken in Home FORMTEXT ?????Guardian 1: FORMTEXT ????? / Relationship FORMTEXT ????? Home Phone FORMTEXT ????? Cell Phone FORMTEXT ?????Address FORMTEXT ????? Email Address FORMTEXT ????? Business FORMTEXT ????? Business Phone FORMTEXT ????? Custody of Student? FORMDROPDOWN Lives with Student? FORMDROPDOWN Receives Mailings? FORMDROPDOWN Guardian 2: FORMTEXT ????? / Relationship FORMTEXT ????? Home Phone FORMTEXT ????? Cell Phone FORMTEXT ?????Address FORMTEXT ????? Email Address FORMTEXT ????? Business FORMTEXT ????? Business Phone FORMTEXT ????? Custody of Student? FORMDROPDOWN Lives with Student? FORMDROPDOWN Receives Mailings? FORMDROPDOWN Is a guardian actively serving in the Military/Reserves: FORMDROPDOWN If so which branch FORMTEXT ?????Parent Signature FORMCHECKBOX (Electronic submission of this form provides an electronic Date FORMTEXT ????? signature which indicates your acceptance of all terms and conditions of application) Please make sure all information is correct. Giving of fraudulent information will be subject to exclusion from the lottery or expulsion from school during the year if discovered. Parents, by signature, understand that actually filing an application does not mean enrollment confirmation and that it will be necessary to reapply each year. We agree that our child may be utilized for any and all testing programs carried out at University School in conformance with the needs of East Tennessee State University in those areas requiring laboratory school students. If and when the applicant can be enrolled, parents will be notified. The annual drawing is in the spring of each year. University School reserves the ability to dismiss a student for just cause or violation of any contract. If the violation is of such gravity or if failure to make satisfactory progress occurs, the student can be dismissed immediately forgoing any further contracts. IT IS THE OBLIGATION OF THE PARENT/GAURDIAN TO KEEP THE INFORMATION ON THIS FORM CURRENT. FORMCHECKBOX Submit on Line:Choose Office or File ButtonSave and Send as Email AttachmentEmail to readg1@etsu.edu ORReturn to: University School ETSU CampusATTN: Dianna ReaAddress: Box 70632 Johnson City, TN 37614ETSU 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. Rev. 11/2017 ................
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