Baconton Community Charter School
 
Application for Admittance

 
                              260 East Walton Street
                            Baconton, Georgia 31716

                                               Phone-(229)-787-9999 Fax-(229)-787-0077

                                                                  Web site: www. bccsblazers.org

 

 

Student’s Name:

 

Date of Birth:
Month/day/year
Social Security #

 

 

 Race:

 

 
 
Sex:
M/F

 

 

Grade entering:

 

 

 School now attending:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MOTHER’S NAME: ________________________________________

(If Guardian, not parent, please list relationship)

ADDRESS: _______________________________________City _____________________County ___________________Zip______

PHONE NUMBERS: Home __________________ Cell _________________ Work _______________ Other________________

PLACE OF EMPLOYMENT: ____________________________________________________________

Marital Status: Single_____ Married_____ Custodial Parent: yes____ no_____

 

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FATHER’S NAME: ________________________________________

ADDRESS: _______________________________________City _____________________County ___________________Zip______

PHONE NUMBERS: Home __________________ Cell _________________ Work _______________Other________________

PLACE OF EMPLOYMENT: ____________________________________________________________

Marital Status: Single_____ Married_____ Custodial Parent: yes____ no_____

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Address Verification: _______ Phone bill _______Power Bill Voter Registration_______

 

I/we, the parent(s)/guardian(s) of the above named student(s), are

applying for application to Baconton Community Charter School. In doing so, I/we agree to the following statements listed in the attached Family Contract, the Conduct Code, and the BCCS Handbook.

 

By signing this application, I am stating that I have read the Family Contract, the Conduct Code, and the Handbook, and I understand what is expected of me as a parent/guardian.

___________________________________ ____________________ (Signature of Parent/Guardian) Date

___________________________________ ____________________

(Signature of School Official) Date

 

 

 

Due to a mental or physical handicap, illness, or family emergency, the following provisions have been made:

Only complete this section if you are unable to fulfill the obligations in the attached Family Contract, Conduct Code, and Handbook. A letter detailing the reason(s) for this exemption must be attached. We will also need the signature of the appointed mentor should you have the need for someone to serve in this capacity for your child.

Hardship Exemption: I am currently unable to volunteer ten hours per nine weeks, but I agree to make a reasonable effort to volunteer _____ hours per nine weeks and to notify the school when it becomes possible to volunteer according to the needs of the school. I understand that hardship exemptions are subject to the Governing Board’s approval.

Mentor Clause: I hereby give permission to ____________________________serve as mentor for my child and to participate on behalf of my child as required by the BCCS Family Contract. I understand that all mentors must submit to fingerprinting and criminal background checks before accepting mentoring responsibility. I hereby waive any and all claims or causes of action I may have now or in the future individually or on behalf of my minor child against Baconton Community Charter School, the Mitchell County Board of Education, their agents, employees, or representatives, resulting from or arising out of any act, error, or omission of the mentor I have appointed herein.