SAMPLE

XYZ Charter

719 Fourth Street

Anytown, TX

555/555-1234

LOTTERY REGISTRATION FORM

School Year 20__ – 20__

Dear Parents,

XYZ Charter is currently filled to capacity. As openings become available Federal/State Law requires that the charter school select new students through a lottery system. If you choose to have your student placed in the lottery, please complete the form below and return it to the school.

Last Name First Name Middle Name

School ________________________________ Grade ______ Birth Date _____/_____/_____

SSN ___________________________________ Age on September 1, 20XX_____________

Home Address _______________________________________________________________

City ______________________________ State ___________ Zip _____________________

Home Phone _______________________ Birthplace ________________________________

First Parent/Guardian ______________________________ Relation ____________________

Address ____________________________________________________________________

City ______________________________ State _________ Zip _______________________

Home Phone ______________________ Work Phone _______________________________

Place of Employment__________________________________________________________

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