Huntington Charter School

Huntington Charter School New Student Dormitory Application

District policy stipulates that only students enrolled in grades 9-12 will be allowed to live in dormitory.

We look forward to hearing from you and receiving your application materials. Applications will be screened by the Dormitory Residence Committee in the order they were received. Approved applicants will be notified by phone or mail. Upon approval the district may require additional information from the student and their legal guardians.

If you have any questions please feel free to contact the District Office at (541) 869-2204 or visit our website at http://www.huntington.k12.or.us/home

Please provide an answer to all questions and provide as much detailed information as possible to assist the screening committee with their decision. Incomplete applications, false information, and/or failure to provide adequate information may result in your application being rejected.

Upon completing the application please submit it to the following:

Huntington Charter School

Attn: Shelley Guerri

520 Third Street East

Huntington, OR 97907

[email protected] Student Information

Student Name:

______

Last First Middle

Date of Birth: (mm/dd/yyyy) ___/_____/______Sex: ___ Male ___ Female

Home Phone: (____)______Cell: (____)______Emergency: (____)______

Home Address: ______

Street City

______

State Zip

Email Address: ______

Parent/Guardian Information

Fathers Name: ______

Fathers Occupation: ______

Fathers Home Phone: (_____)______Fathers Cell: (_____)______

Fathers Address: ______

______

Mothers Name: ______

Mothers Occupation: ______

Mothers Home Phone: (_____)______Mothers Cell: (_____)______Mothers Address: ______

______

In case of emergency contact: ______(_____)______

Previous School Information

Name of School Previously Attended: ______

Grade Level: ______GPA: ______

School Address: ______

Street City

______

State Zip

School Phone: (_____)______

List the high school or community activities in which you participated:

______

Huntington Charter School Information The Huntington Charter School strongly encourages all dormitory students to participate in school related activities, community activities, school sponsored athletics, and other extracurricular activities. Please list activities in which you plan or have interest in participate in during the school year:

______

Areas of Academic Interests

______

Dormitory Rules and Contract

Please read the Huntington Dormitory Contract and Rules by clicking the link found on the “Huntington Dormitory” link. Please check the box below to indicate that you have read and agree to abide by the guidelines and policies outlined. This box must be checked or your application will not be accepted.

 I have read and agree to abide by the terms of the 2016-2017 Huntington Dormitory Rules and Regulations and other District Policies regulating the behavior and conduct of students. I understand that by violating any rules, regulations, or district policies I will be subject to disciplinary action and possible expulsion from the dormitory.

______Parent/Guardian Signature Date

______

Parent/Guardian Signature Date

______

Student Signature Date