HCA
Hale Charter Academy 
23830 Califa St., Woodland Hills, CA  91367
Telephone (818)313-7400 Fax (818)-346-7517 

2012-13
Charter Open Enrollment Lottery Application
Application period is from April 9 through May 9, 2012
    Transportation is not provided

STUDENT INFORMATION

Child #1 
Last Name:______________________  First Name:_________________________MI:_____
DOB:________________       Gender: ______Male  ______Female
Grade attended at last school___________                       Grade entering in August_________
Last school attended__________________________________________________________

Child #2 
Last Name:______________________  First Name:_________________________MI:_____
DOB:________________       Gender: ______Male  ______Female
Grade attended at last school___________                       Grade entering in August_________
Last school attended__________________________________________________________

PARENT/GUARDIAN CONTACT INFORMATION

Parent/Guardian #1:________________________________Relationship to child:________

Address:____________________________________________________________________
                                                                                     City               State              Zip
Home (___)_______________________             Work (___)__________________________  
  
Cell    (___)_____________________________  Email;______________________________

Parent/Guardian #2:________________________________Relationship to child:________

Address: ___________________________________________________________________
                                                                                     City               State              Zip
Home (___)_______________________             Work (___)__________________________  
  
Cell    (___)_____________________________  Email;______________________________

Are any siblings CURRENTLY attending Hale Charter Academy?  ______Yes ______No	

If yes, please list name (s)______________________________________________________
 
Do you currently live within the boundaries of Los Angeles Unified School District?_____Yes____No

Upon acceptance into Hale Charter Academy, a birth certificate, proof of residence, immunization records and (if applicable), a copy of current IEP must be provided for verification.

All prospective students will be given the opportunity to enroll regardless of race, color, national or ethnic origin, religion, gender, economic social status, or special needs.

PARENT/GUARDIAN STATEMENT

I understand that any false or incorrect information on this application could jeopardize my child’s enrollment should he/she be selected to attend Hale Charter Academy.

I certify that all the answers given in this enrollment application are true.

_______________________________________________________    __________________
                         Parent/Guardian Signature                                                            Date

Application period is from April 9 through May 9, 2012

Drawing to be held on May 11, 2012 in the
Hale Charter Academy Library at 8:30 am