2010-2011 ENROLLMENT LOTTERY APPLICATION

Please print all information clearly. Only complete applications will be considered.
APPLICATIONS DEADLINE FOR 5TH GRADE EXTENDED: Monday, May 10th
Lottery Date: Thursday, May 13
Location: Fatima Hall, 11 Fatima Drive, Cumberland RI

Any applications received after the May 10, 2010 deadline will be placed at the bottom

of the waitlist in the order that they are received.

* Required

I am submitting this application on behalf of my child who will be entering the following grade in August, 2010: *

Kindergarten (no longer available)
1st Grade (no longer available)
5th Grade

STUDENT INFORMATION

Last Name: *

First Name: *

MIddle Name:

Address: *

City: *

Zip *

FAMILY INFORMATION

Parent/Guardian 1 Relationship to student

Lives with student? *

Last Name: *

First Name: *

Phone Info (Primary, Home, Work, Cell): *

Address: *

City: *

Zip *

Parent/Guardian 2 (optional) Relationship to student:

Lives with student?

Last Name:

First Name:

Phone Info (Primary, Home, Work, Cell):

Email:

Address:

City:

Zip

Is your child eligible for free or reduced price lunch?
To review eligibility chart, click here. Make sure you allow popups.

Yes
No
Unsure

By state statute, Democracy Prep Blackstone Valley is required to serve the same (or higher) percentage of disadvantaged students as the districts we enroll from. Democracy Prep, uses Free and Reduced Price Lunch eligibility to ensure that our school population represents the communities we serve in terms of economic disadvantage or that we serve a higher percentage of economically disadvantaged students as our sending districts of Central Falls, Cumberland, Lincoln, and Pawtucket.

Note:

- Separate applications must be completed for each student.
- There is no admissions exam.
- Democracy Prep Blackstone Valley is a FREE PUBLIC SCHOOL and does not discriminate in any way including on the basis of ethnicity, national origin, religion, gender, academics or disability.

Signature:

We affirm that the information contained in this application is, to our knowledge, completely true, and that my child would be eligible to attend kindergarten, first grade, or fifth grade in Central Falls, Cumberland, Lincoln or Pawtucket. In applying to Democracy Prep, I agree the school may use photo or video materials of my child for outreach and that school records may be used for studies on the effectiveness of charter schools. In publicized studies only group data, not student level data, will be reported. Sensitive student information will remain confidential under state and federal law.”

Need Help?

PLEASE CONTACT OUR HOTLINE IF YOU WOULD LIKE ASSISTANCE COMPLETING THIS FORM: 800.971.3090 or 401.244.7496 Applications can be mailed to Rhode Island Mayoral Academies, 160 Westminster Street, Suite 202, Providence, RI 02903 or emailed to This e-mail address is being protected from spambots. You need JavaScript enabled to view it You may also apply online at: www.mayoralacademies.org Upon receipt of this application, Rhode Island Mayoral Academies will send a confirmation letter, either electronically via email or via the United States Postal Service.

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