BROOKLYN SCHOOL OF EXCELLENCE APPLICATION2023-2024 FIRST NAME LAST NAME PREFERRED DATE OF BIRTH OSIS NUMBER GENDER ADDRESS City State Zip HOME PHONE CELL PHONE Do you have any siblings at NY Smart Start? Yes No Name(s): Student lives with: Both Parents Father Mother Other If parents are separated or divorced, is the non-custodial parent to receive a copy of grade report? Are there any restrictions on the non-custodial parent? If yes, explain and include a copy of court papers: Download court papers Grade entering Last School Attended Address Was the student allowed to re-enroll in the previous school? Yes No If NO, please explain: Did the student fail any classes the previous years? Yes No If YES, please explain: If registering mid-year, is the student failing any classes? Yes No If YES, please explain: If registering mid-year, could the student continue at the currently enrolled school at time of withdrawal? Yes No If NO, please explain: Has the student ever repeated or skipped a grade? Yes No If YES, please explain: Has the student ever been homeschooled? Yes No If YES, what grades? Does the student have any learning difficulties? Yes No If YES, please explain Has the student ever been professionally tested for one of the following: ADD/ADHD, SLD Hearing, Vision, Speech or any other? Yes No If YES, discuss the results and include a copy of the report Copy of the report by ADD/ADHD, SLD Hearing, Vision, Speech or any other Has the student ever been suspended from school? Yes No If YES, please explain: Has the student ever been expelled from school? Yes No If YES, please explain: Has the student had a behavioral problem? Yes No If YES, please explain: FATHER’S NAME FATHER’S LAST NAME Occupation: Place of Employment: Address if different from student’s: Home Phone: Work Phone: Cell Phone: Father’s Email: College attended: Degree achieved: MOTHER’S NAME: MOTHER’S LAST NAME: Occupation: Place of Employment: Address if different from student’s: Home Phone: Work Phone: Cell Phone: Mother’s Email: College attended: Degree achieved: Name of the person(s) responsible for the student’s tuition: Relationship to student: Emergency Contacts. Please list two people other than parents: I agree to specify two Emergency contacts Name: Relationship to student: Home Phone: Cell Phone: Name: Relationship to student: Home Phone: Cell Phone: Send
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