* Required Fields
Last Name:
First Name:
Middle Name:
Address:
City:
Zip Code:
Home Phone:
District of Residence:
Date of Birth:
Grade:
Gender:
Relationship:
Cell Phone:
Employer:
Work Hours:
Work Phone:
Alternate Phone:
Alternate Phone Type:
Email:
Parent Marital Status? Single Married Divorced Widowed Separated
Is student living with both parents? Both Father Mother Guardian Foster
Legal Custody? Joint Father Mother Guardian State Temporary
School Last Attended:
Grade Last Attended:
School District:
Did your child have special education services provided at a previous school? Yes No
If yes, what services?
Is your child currently on an Individual Education Plan (IEP)? Yes No
Is your child Limited English Proficient (LEP)? Yes No
Has your child been enrolled in an English Immersion Program? Yes No
7. How / Where did you hear about Benton Harbor Charter School: Benton Spirit Herald Palladium Movie theater ad WVBH 105.3 FM WSMK 99.1 FM Direct mailer Handout Billboard Event Friend/Family Other
Which Event:
Other Details:
Friend or Family Members Name:
Name:
Birth Date:
School:
Once you have completed all required fields and agree to the terms (by checking the box the box below) your application is now ready to submit! Please click "Submit Application" button. A confirmation email will be sent to the email address listed under legal guardian one. By checking this box, I certify that all information provided in this application and in all accompanying forms is true, accurate, and complete.
*You must first check the box above in order to submit your application.
