Student First Name *
Student's Last Name *
Student's Date of Birth *
Student's Gender *
Entering Grade Level *
--- Select a grade ---
Kindergarten
First grade (1)
Second grade (2)
Third grade (3)
Fourth grade (4)
Fifth grade (5)
Sixth grade (6)
Seventh grade (7)
Eighth grade (8)
Ninth grade (9)
Tenth grade (10)
Eleventh grade (11)
Twelfth grade (12)
Current School *
Please select the academic year for which you seek enrollment *
--- Select an academic year ---
2011 - 2012
2012 - 2013
School for which enrollment is sought *
--- Select a school ---
KIPP Blytheville College Preparatory School (5-8)
KIPP Delta College Preparatory School (5-8)
KIPP Delta Collegiate High School (9-12)
KIPP Delta Elementary Literacy Academy (K-4)
Home Address
Street Address *
Address Line 2
City *
State *
-- Select a State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code *
Parent/Guardian Information
Parent/Guardian First Name *
Parent/Guardian Last Name *
Parent/Guardian Home Phone *
Parent/Guardian Work or Cell Phone *
Parent/Guardian Email Address
What is your relationship with the student? *
What is the best way to
-- Please select an option
Home phone
Cell/work phone
Email
Regular mail
Will the student need bus transportation? *
Does your child have a sibling at KIPP? If so, please write their name here:
Other Please note that
entering a student’s name below does not enter him/her in the KIPP Delta Public Schools Lottery.
Full Name:
Interested student's current grade:
--- Select a grade ---
Kindergarten
First grade (1)
Second grade (2)
Third grade (3)
Fifth grade (5)
Sixth grade (6)
Seventh grade (7)
Eighth grade (8)
Ninth grade (9)
Tenth grade (10)
Eleventh grade (11)
Interested Student's Parent:
Interested Student Parent's Phone:
How did you hear about KIPP Delta Public Schools? *
--- Please make a selection ---
Friend
Newspaper advertisement
Billboard in town
Television advertisement
Radio advertisement
Another KIPP website
Already have another child at KIPP
Other
If "other," please tell us how:
Research Consent
KIPP Delta Public Schools is participating in research studies of our student outcomes. Please read the following statement.
I understand that as part of KIPP Delta Public School’s commitment to continual improvement, KIPP Delta is involved in
studies of student outcomes. In submitting this application, I grant permission for KIPP Delta or its research partners*,
including Mathematica Policy Research and the University of Arkansas, to request the school records of the student for
whom I am submitting this application, including such information as my child's attendance, test scores, or other academic
outcomes, for the duration of the studies. I further understand that this information may be used for other studies of
KIPP Delta and that all student-level information will remain confidential as required by the Family Educational Rights
and Privacy Act (FERPA). My decision whether or not to participate in a study will have no impact on my child’s likelihood
of admission to KIPP Delta. Further, there are no discernible risks to participating in the study, and while there are no
direct benefits to myself or my child, KIPP and society at large may benefit from the increased knowledge about potential
KIPP student achievement and parental satisfaction.
After reading the above statement, do you give permission for your child to participate in the KIPP study? * Yes, my child CAN participate in the study, and I authorize his/her school, district or state to release his/her administrative records. No, I do NOT consent for my child to participate in the study.
Signature
The electronic signature below, and all of its related fields, replaces a handwritten signature on paper and is legally binding.
I attest that I am the legal parent or guardian of the student named above. I affirm that the information I have submitted is
true and accurate to the best of my knowledge. I understand that all information will be verified and providing incorrect information
can result in application disqualification or loss of seat. Additionally, I understand that submitting an application does not guarantee
admission to KIPP Delta Public Schools.
*
Questions
If you have any questions about the study or your child’s participation, please contact Lisbeth Goble at Mathematica’s toll-free number, 1-877-523-4651. For questions about your rights as a research participant, or if you feel that you have been harmed in any way as a result of study participation, please contact Margo Campbell at Public/Private Venture’s IRB at toll-free 1-800-755-4778 x4446.
