Office Use Only

Date Received: ___________

2011 -2012 Student Application

Please return completed and signed application along with supporting documents to: Hardy Brown College Prep 190 Carousel Mall San Bernardino, CA 92401
Hardy Brown College Prep Line: (909) 884-1410

Required Supporting Documents Copy of Birth Certificate Copy of Immunization Records Residence Verification ( i.e. Utility Bill, Mortgage or Rental Agreement) Copy of Report Card, and Discipline Record from Current School Copy of STAR test results from current school (if applicable) Report of Health Examination for School Entry (Kindergarten) Copy of Current IEP or 504 (Special Education) Copy of Valid California Drivers License

Personal/Demographic Information (please print neatly)

School Year applying for: 2011 - 2012 Students Last Name (Residence) Street Address (Mailing) Street Address Primary Phone # Secondary Phone # Grade Applying For: (Circle One) K First Name City City Date of Birth (MM/DD/YY) Gender: Male / Female SSN: State State 1 2 3 4 7 Middle Initial Zip Zip

Present Home School of Attendance / Home School District Years Enrolled in California Schools: Mother/Guardians Last Name (Residence) Street Address Home Telephone # Cell Phone # Occupation E-mail Address: Education Level (Circle One): Not a High School Graduate College Graduate Father/Guardian Last Name (Residence) Street Address Home Telephone # Cell Phone # Occupation E-mail Address: Education Level (Circle One): Not a High School Graduate College Graduate

Has the student ever enrolled at Hardy Brown College Prep? YES or NO (Please circle) First Name City Work Telephone # Employer State Middle Initial Zip

High School Graduate Graduate Degree or Higher First Name City

Some College or Associate Degree Decline to State Middle Initial State Zip

Work Telephone # Employer

High School Graduate Graduate Degree or Higher

Some College or Associate Degree Decline to State

Day Care Information (if applicable)

Day Care Provider Name Street Address E-mail Address: Work Telephone # Cell Phone # City State Zip

Emergency Contact Information

First Contact/ Last Name Street Address E-mail Address: Second Contact/ Last Name Street Address E-mail Address: First Name Telephone # Cell Phone # City Relationship State Zip First Name Telephone # Cell Phone # City Relationship State Zip

Medical Information
Insured/ Last Name Name of Health Insurance Allergies Doctors Last Name First Name Medical ID # / Policy # Medical Problems/Chronic Illness First Name M.I. Telephone # Other Issues Telephone #

Home Language Survey

Which language did your son or daughter learn when he or she first began to talk? What language does your son or daughter most frequently use at home? What language do you use most frequently to speak to your son or daughter? Name the language most often spoken by the adults in the home. Was your child previously enrolled in ESL / Bilingual Program?

Name(s) of Brothers and Sisters

Last Name First Name M.I. Gender Current School Grade Level

Instructional Programs Information

Has your child ever been retained? If so, what grade? Has your child ever been enrolled in any type of special program? If yes, answer questions below. Please complete the following only if your child has been enrolled in any type of special instructional programs at his/her previous school(s): Has your child ever received resource specialist program services? Has your child ever received speech services? Has your child ever been in a self-contained special education class or learning center? Has your child been GATE identified? Does your child have a current IEP or 504? If Yes, please submit copy of current IEP or 504 with application.

Ethnic city: Note: The information colllected in regard to ethnicity is be collected fo data purposes only and schoo officials will not use the e eing or s ol inform mation to make a admission decisio ons. The standa for classification of race and data mirror tho standards us by the feder government ards d ose sed ral for determining ethnic and race. city Is the student Hispanic or Latino? (se only one) elect tino Yes, Hispanic or Lat No not Hispanic or Latino o,

The above part of the question is about ethnicity, not race. No matter what you selec above, YOU MUST CONTIN TO ANSWER THE r cted U NUE FOLL LOWING by mark one or more boxes. king e Race: Note: The info : ormation collecte in regard to ra is being colle ed ace ected for data pu urposes only and school officials will not use the information to s e make admission decis sions. The stand dards for classifi fication of race and data mirror th hose standards u used by the fede government for determining eral t g ethnic and race. city What is the race of thiis student? (Sellect one or more e) American Indian o Alaskan Nativ or ve* Cambodian Guamanian G Ja apanese Other Asian O Ta ahitian Other: ________ O ______________ __________ Asian Indian n Black or Afric American can Chine ese Filipino Hmong Hawa aiian Laotian Korea an Samoan Other Pacific Islander r White** Vietnamese Multi-Racial: ______ ______________ _____________ ______________ _______ Include all races that ap e pply

*Perso having origin in any of Nort Central or So America ons ns th, outh **Pers sons having origins in Europe, North Africa, or th Middle East N he

Residence
This in nformation is fed derally mandated for reporting pu d urposes as part of the McKinney y-Vento Assistan Act (42 U.S.C. 11431 et se nce eq.) Where is your child/fa e amily current livin (CHECK ONE ng E)? In a single fa amily permanen regular and ad nt, dequate residence (house, apar rtment, condo, m mobile home) Temporarily double-up (sha y aring housing wit other families/ th /individuals due to hardship) In a shelter or transitional ho ousing program In a motel/hotel In a car or R RV In a campsit te At another lo ocation (please specify)_______ _____________ ______________ _____________ ______________ ____________

Gene Authoriz eral zations

In an e emergency, whe I cannot be re en eached, I authorize the school au uthorities to take my student, at my expense, to my family docto licensed e or, physic cian, nearest hos spital or emerge first aid stat for treatmen This consent iis effective until revoked in writin ency tion nt. ng (Pleas initial next to s se selection): Yes, I do give permission ___ e __________ No, N I do not give permission____ _________

At times during the ye the media may request perm ear, m mission to write a article about, and/or take pictures of, an activ taking place at the school an vity site. A Additionally, storiies and photos of students may be taken for incllusion on the Fo o ortune School we ebsites, newslett and promotio materials ter onal (Pleas initial next to s se selection): e __________ Yes, I do give permission ___ No, N I do not give permission____ _________

I affirm to the best o my knowledg that the abo information is correct and that I will notify the school ea time there is a change in m, of ge, ove y ach s any o this information. of Date (MM/DD/YY) Paren nt/Guardian Signature NO OTICE OF NON DISCRMINATO POLICY ORY Hardy Brown College Prep admits stu y udents of any rac color, nationa and ethnic orig Hardy Brow College Prep does not discrim ce, al gin. wn minate on the basis of race, color, na ational and ethn origin in administration of its e nic education policie admission po es, olicies, scholarsh and loan programs, and hip athletiic or other schoo administered programs. The s ol p schools adminis stration and staff recognize the r f rights and privile eges of all studen School nts. spons sored programs a activities are made available to all students at the school. and e e

COMMITMENT TO EXCELLENCE CONTRACT

TEACHERS COMMITMENT We fully commit to Hardy Brown College Prep in the following ways: o We will be prepared to teach and be in our classrooms every day by 7:30 a.m. o We will maintain professional standards for appearance and a positive attitude. o We will always teach in the best way we know how, and we will do whatever it takes for our students to learn. o We will work collaboratively with fellow teachers, our Principal and all support staff. o We will always make ourselves available to students and parents, and listen to any concerns they might have. o We will always protect the safety, interests and rights of all individuals in the classroom. _______________________________ TEACHER SIGNATURE ____________________________________ DATE

PARENTS/GUARDIANS COMMITMENT We fully commit to Hardy Brown College Prep in the following ways: o We will make sure our child is in the classroom every day by 7:45 a.m. o We will make arrangements so our child can remain at HBCP until his/her grade-level dismissal time. o We will pick our child up on time upon dismissal from school. o We will ensure that our child attends any required HBCP after school, intersession and/or summer school sessions. o We will always help our child in the best way we know how, and we will do whatever it takes for him/her to learn. This also means we will check our childs homework every night, let him/her call the teacher if there is a problem with the homework, read with him/her every night, and provide 40 hours of approved family service. o We will always make ourselves available to our children, the school, and any concerns they might have. This also means that if our child is going to miss school, we will notify the HBCP office as soon as possible, and we will read carefully all the papers that the school sends home to us. o We will allow our children to go on HBCP field lessons. o We will make sure our child wears the HBCP uniform and follows the HBCP dress code. o We understand that our child must follow the HBCP rules so as to protect the safety, interests, and rights of all individuals in the classroom. We, not the school, are responsible for the behavior and actions of our child. o We will always protect the safety, interests and rights of all individuals in the classroom. I acknowledge that failure to adhere to these commitments can cause my child to lose various HBCP privileges, and can lead to my child returning to his/her home school. _______________________________ PARENT SIGNATURE ____________________________________ DATE

STUDENTS COMMITMENT We fully commit to Hardy Brown College Prep in the following ways: o I will be in my classroom and ready to learn every day by 7:45 a.m. o I will remain at HBCP until my grade-level dismissal time. o I will attend any required HBCP before/after school, intersession and/or summer school sessions. o I will always work, think, and behave in the best way I know how, and I will do whatever it takes for me and my fellow students to learn. This also means that I will complete all my homework every night, I will call my teacher if I have a problem with the homework or a problem with coming to school, and I will raise my hand and ask questions in class if I do not understand something. o I will always make myself available to my parents, my teacher, and any concerns they might have. If I make a mistake, this means I will tell the truth to my teacher or Principal and accept responsibility for my actions. o I will always behave so as to protect the safety, interests and rights of all individuals in the classroom. This also means that I will always listen to all my HBCP teammates and give everyone my respect. o I will wear a HBCP uniform and follow the HBCP dress code. o I am responsible for my own behavior, and I will follow my teachers directions. I understand that failure to adhere to these commitments can cause me to lose various HBCP privileges, and can lead to returning to my home school. _______________________________ ____________________________________ STUDENT SIGNATURE DATE

REQUEST FOR CUMULATIVE RECORDS

FROM: Hardy Brown College Prep 190 Carousel Mall San Bernardino, CA 92401 909-884-1410 Fax: 909-889-5002 TO: ____________________________________ (Previous School Name) ____________________________________ ____________________________________ RE: ____________________________________ (Student Name)

We have received authorization to request the cumulative records of the above listed student(s). Below is our authorization. Please fax the documents to HBCP, Registrar at 909-889-5002. Please contact HBCP directly at 909884-1410 with any questions. Authorization to Request Cumulative Records
I hereby request and authorize my childs previous school located at: Street Address School District City State Zip Telephone # - -

to forward the confidential records of my child to Hardy Brown College Prep. Date (MM/DD/YY)

Parent/Guardian Signature

Parent/Guardian Name (print)