STEM Application

Application for Admission for the 2010-2011 School Year

Notice: This is a 2 part application. Section 1 can be completed online. After submission of Section 1, you will need to download Section 2 and print this document, complete the relevant sections, and submit by mail before your child will be considered for admission for the 2010-2011 school year. The deadline for first round consideration is April 1, 2010.

Some of the information such as race, previous academic achievement, OAT scores, economic disadvantagement, etc. will not be used to determine acceptance to The Dayton Regional STEM School. This information is collected to know more about the applicant pool at DRSS and to have on file should you be accepted.

Student Requirements for Admission:

Student is a current resident of Clark, Greene, or Montgomery County; (or will be following relocation)

Student is not under suspension/expulsion from home district;

Student is currently drug free.

For students entering 9th grade — Student must be NO OLDER than 15 by September 1, 2010

Student attended 7th or 8th grade in the 2009-2010 school year and will be promoted/assigned to the 8th or 9th grade

STUDENTS ENTERING GRADE 10, MAY NEED TO MEET ADDITIONAL REQUIREMENTS PRIOR TO ACCEPTANCE

* Required Fields

Student Information

Student First Name:

*

Called Name:

Student Middle Name:

Student Last Name:

*

Student Birthplace:

*

Entering Grade:

*

Address One:

*

Address Two:

City:

*

State:

*

Zip:

*

Student's E-Mail Address:

Student Primary Phone:

Student Secondary Phone:

Student Gender:

*

Do you have an IEP:

*

*Do you have a 504:

Student Ethnicity - Please check only one (required by federal law):

*

Student lives with:

Guardian Housing Arrangement:

Are there custody papers?

If there are custody papers, what is the date of the most recent court order? (MM/DD/YY)

Information below required for all custodial persons with whom you live (Please complete at least 2 of the phone numbers and one of the email addresses for Custodial Person 1):*

Custodial Person 1
First Name		Last Name		Relation
Home Phone		Cell Phone		Work Phone
Other Phone		Home Email		Work Email

Custodial Person 2
First Name		Last Name		Relation
Home Phone		Cell Phone		Work Phone
Other Phone		Home Email		Work Email

What language is spoken at home? English Other

Have you attended kindergarten?
Yes No
If yes, was it: Full Day Half Day

Emergency Contact information if parents/guardians cannot be reached.
Last Name		First Name		Relation
Home Phone		Other Phone
Address

Transportation that you are considering:

Existing RTA or Greene CATS route
Dedicated RTA or Greene CATS route (only DRSS students)
Local school bus route (not available in all districts)
Car Pool
Parent Drive

Are you willing to allow DRSS to share your contact information with other parents to assist in potential car pooling opportunities?

Applicant School Information

Which school district do you currently reside in?

*

Name school of attendance in 2008-2009:

Do you plan to participate in extra curricular activities in your district of residence?

If yes, which activities and at which high school?

Were you on free or reduced lunch during the last school year?

*

How did you find out about the Dayton Regional STEM school?

E-mail: info@daytonstemschool.org