Cesar Chavez Academy Student Registration

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Cesar Chavez School Network

Student Enrollment Application

Cesar Chavez Academy
Dolores Huerta Preparatory High
CCA-Central-Colorado Springs

By filling out this form, you reserve your child a place in the lottery, but it does not obligate your child to attend.

Please Read Prior to Filling Out the Application !!! If you are applying for a future Kindergarten class, please indicate the year your child will be entering kindergarten.
Kindergarten:The child must be 5 years of age on or before 06/01/07

Fields marked with an asterisk (*) are required

Child's Information

*Child's last name:
*Child's first name:
*Child's middle name:
*Child Social Security Number (XXXXXXXXX no dash):
*Please enter which school you are applying to (CCA, DHPH, CCA-Central):
*Child's date of birth (MMDDYYYY):
*Grade Level in school year 2007/2008:
Last school child attended:

Address:

*Address:
*City:
State:
Zip:

Parent's info

*Mother's (Guardian) Last name:
*Mother's (Guardian) First name:
*Father's (Guardian) Last name:
*Father's (Guardian) First name:

Contact Information

Home Telephone:
Work Telephone:
Cell Phone:
Emergency Telephone 1:
Emergency Telephone 2:
Your e mail:

Siblings

*Do you have a sibling currently attending or that has already been accepted to CCA or DHPH?	Yes No
If yes, please give names: Last name First name Grade
* Do you have other siblings attending or that currently been accepted to CCA or DHPH?	Yes No
If yes, please give names: Last name First name Grade

Extra Info

*Is your child a candidate for the Honors Program ( 5th - 8th Grade)	Yes No
*Does your child require special educational accomodations:	Yes No
*Would you be interested in full day kindergarten?	Yes No
*From who or where did you hear about CCA, DHPH or CCA-Central?
*Are you a resident of Pueblo County?	Yes No
*Do you or your spouse work for the federal government?	Yes No
*Will your child be eligible for the free or reduced lunch program?	Yes No
*Extra curricular activities. Please check all that apply, you must select at least one option. If your selection is a Musical Instrument please enter the instrument type in the text box below.	Musical Instrument Football Softball Basketball Wrestling Cross County other

PLEASE NOTE THAT IF YOUR ADDRESS OR PHONE NUMBER CHANGES, IT IS YOUR RESPONSIBILITY TO INFORM THE SCHOOL. YOUR CHILD MAY NOT BE ACCEPTED IF THIS INFORMATION IS NOT UP-TO-DATE.

I intend to enroll my child at Cesar Chavez Academy, Dolores Huerta Preparatory High or CCA-Central-COS. I have been explained the components of the curriculum as outlined in the brochure or at www.cesarchavezacademy.org or www.ccacentral.org. I understand that the locations of each school are 2500 W.18th St. , Pueblo, CO 81003 or 3115 Larkspur, Colorado Springs, CO 80907. I also understand that the admissions process will be by lottery and sibling preferences.

When using Internet Explorer ONLY you may encounter a Stack Overflow error. If you receive this error click on the ok button and your application will still be processed. Sorry for the inconvenience. CCA Webmaster

Submitted by(First name, Last name):

Submit Date:

Please review your application information and make any corrections necessary. Be sure to click Submit when you are finished.

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Cesar Chavez School Network

Student Enrollment Application

Cesar Chavez AcademyDolores Huerta Preparatory High CCA-Central-Colorado Springs

Cesar Chavez Academy
Dolores Huerta Preparatory High
CCA-Central-Colorado Springs