CMS Admissions Application Part One

Read all instructions before submitting your application.

Incomplete applications will not be accepted.

Please note that you cannot save the application online.

A Word version of the application is available here. Applications may be submitted through this online form or typed in the Word file.
Una aplicacion en Español esta disponible aquí.
In addition to the application, you must supply the following documents by emailing them to or mailing to
Cornelia Connelly Center
220 East 4th Street
New York, NY 10009
  • Copy of student’s birth certificate
  • Completed 2016 tax return (form 1040) and last two pay stubs
  • Proof of Social Security benefits or Public Assistance (if applicable)
If you have questions, please contact

Policy of Non-Discrimination: Cornelia Connelly Center - Connelly Middle School admits students of any race, color, creed, or national origin to all rights, privileges, programs, and activities generally accorded or made available at the school. Cornelia Connelly Center - Connelly Middle School does not discriminate on the basis of race, color, creed, or national origin in the administration of its educational policies and scholarship, athletic, and other administered programs.

Student Information
Family Information (Please supply contact information for both parents and/or legal guardians.)
Guardian (if applicable)
Religious Affiliation (optional)
Household Information
Income Information
CCC is committed to serving students who are most in need of our program. As such, we ask parents/guardians to disclose income information as part of the application process. Currently 90% of our students qualify for the federal Free/Reduced lunch program
Monthly Income: Please tell us about ALL sources of income you receive.
Other Adult Supporting Child
Student Description
Parent/Guardian Signature
Please check below indicating you understand and agree to the following:
Code of Conduct and Parental Involvement
It is my understanding that Cornelia Connelly Center - Connelly Middle School is committed to academic opportunities and open to spiritual and social development. Each student will be encouraged to work to her potential and to adhere to a Christian code
of conduct. Families will be required to participate actively in the life of the school (including attendance at meetings, field trips, etc.) in order to meet the requirements of the program.
Attestation Statement
I affirm that the above information is true to the best of my knowledge. I understand that failure to provide the required documentation stops the application process.
Furthermore, should my child be accepted/admitted under false or negligent information, my child will be dismissed from the school.
I agree that should my child be accepted/admitted, my child and I will be bound by the terms and conditions of the school's parent/student handbook. By typing my name below, I am electronically signing this application and agree to the above statements.


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