KHEPERA CHARTER SCHOOL
144 W. CARPENTER LANE * PHILADELPHIA., PA 19119
215-843-1700 (OFFICE) 215-843-3530 (FAX)
WWW.KHEPERACHARTERSCHOOL.ORG
ENROLLMENT FORM FOR 2010-2011 SCHOOL YEAR
DATE:_________________
DATE OF BIRTH OF STUDENT: _______________________________________
NAME OF STUDENT:____________________________________________________
PARENTS(S) / (GUARDIAN(S): _____________________________________________________________________
ADDRESS: _______________________________ CITY: __________________ STATE: _______ ZIP: _________
HOME #: __________________________ WORK #: _____________________________
CELL #: __________________________ E-MAIL ADDRESS:_________________________________________
GRADE ENTERING SEPTEMBER 2010: _______________________________
(For Kindergarten, the student must be 5 years old by 9/1/10.
For 1st grade, the student must be 6 years old by 9/1/10).
For 1st grade, the student must be 6 years old by 9/1/10).
SCHOOL PREVIOUSLY ATTENDED: _____________________________________________________
_____________________________________________________
_____________________________________________________
NAME(S) OF SIBLING(S) CURRENTLY ATTENDING KHEPERA CHARTER SCHOOL.
NAME: _____________________________________ GRADE: _________
NAME: ____________________________________ GRADE: _________
NAME: ____________________________________ GRADE: _________
NAME: ____________________________________ GRADE: _________
NAME: ____________________________________ GRADE: _________
NAME: ____________________________________ GRADE: _________
NAME: ____________________________________ GRADE: _________
NAME(S) OF SIBLING(S) REQUESTING ENROLLMENT NOW.
