CMS Admissions Application Part One

Please complete the form below. Required fields marked *

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 admissions@connellycenter.org or mailing to

Admissions
Cornelia Connelly Center
220 East 4th Street
New York, NY 10009

Copy of student’s birth certificate
Completed 2017 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 admissions@connellycenter.org.

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

First Name*

Answer Required

Middle Name

Answer Required

Last Name*

Answer Required

Date of Birth*

Answer Required

Age*

Answer Required

Address*

Answer Required

City*

Answer Required

State*

Answer Required

Zip Code*

Answer Required

Phone Number*

Answer Required

Present School*

Answer Required

Present Grade*

Answer Required

How did you hear about our school? (Please check one)

Answer Required

Current student and/or her family member

Graduate and/or her family member

Saw a flier

Walked past our building

Heard CCC staff member speak

Other:

If other, please describe.

Answer Required

If you saw a flier, please explain where. If you heard a CCC staff member speak, please tell us where.

Answer Required

Family Information (Please supply contact information for both parents and/or legal guardians).

Mother

Full Name

Answer Required

Address

Answer Required

Home Phone

Answer Required

Cell Phone

Answer Required

Employer

Answer Required

Occupation

Answer Required

Work Phone

Answer Required

Father

Full Name

Answer Required

Address

Answer Required

Home Phone

Answer Required

Cell Phone

Answer Required

Employer

Answer Required

Occupation

Answer Required

Work Phone

Answer Required

Guardian (if applicable)

Full Name

Answer Required

Address

Answer Required

Home Phone

Answer Required

Cell Phone

Answer Required

Employer

Answer Required

Occupation

Answer Required

Work Phone

Answer Required

Please check all that apply

Answer Required

Parents live together

Parents are divorced or separated

Mother deceased

Mother remarried

Father deceased

Father remarried

With whom does the student live?*

Answer Required

Religious Affiliation (optional)

Religion

Answer Required

Parish/Church

Answer Required

Ethnic Background (optional)

Answer Required

Hispanic

Asian

Caucasian

Black

Multiple ethnicities

Other

Mother's Birth Place*

Answer Required

Father's Birth Place

Answer Required

Household Information

Please provide the following information for all children ages 0-17 living with the student at the current address: Name, Age, Relationship to Student, School Name*

Answer Required

Please provide the following information for all adults (over 18) living with the student at the current address: Name, Age, Relationship to Student, Occupation*

Answer Required

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

Mother

Gross Monthly Income (before taxes)

Answer Required

Monthly Child Support or Alimony Received

Answer Required

Public Assistance, Social Security Benefits, 2nd Job Income, or any other income

Answer Required

Father

Gross Monthly Income

Answer Required

Month Child Support or Alimony Received

Answer Required

Public Assistance, Social Security Benefits, 2nd Job Income, or any other income

Answer Required

Other Adult Supporting Child

Gross Monthly Income

Answer Required

Monthly Child Support or Alimony Received

Answer Required

Public Assistance, Social Security Benefits, 2nd Job Income, or any other income

Answer Required

How would you describe your student as a learner?*

Answer Required

Student Description

Name three areas where your student is successful.*

Answer Required

Are there any areas (academic, social, emotional, ect.) in which your student needs improvement? Please name them.*

Answer Required

Is there anything else you would like us to know about your student?*

Answer Required

Parent/Guardian Signature

Please check below indicating that you understand and agree to the following:

I understand that CMS has a mandatory new student orientation July 8-12, 2019 at Cornelia Connelly Center*

Answer Required

I understand

I understand that part of her acceptance is to attend a mandatory sleep-away camp in Lake Placid, NY for 3 weeks each summer starting at the end of her 5th grade year.*

Answer Required

I understand

I understand that CMS 4th and 5th grades dismiss at 3:00pm, Monday - Thursday. On Fridays, dismissal is at 1:00pm.*

Answer Required

I understand

I understand that CMS has a school counselor that each student visits on a periodic basis.*

Answer Required

I understand

I understand that CMS does NOT have and ICT (Special Education) class.*

Answer Required

I understand

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.

Signature*

Answer Required

Signature

Answer Required

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 also 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 signing and agreeing to the above statements.

Signature*

Answer Required

Signature

Answer Required

Policy of Non-Discrimination

Cornelia Connelly Center - Connelly Middle School admits students of any race, color, creed or national origin to all rights, privileges 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 administrated programs.

Please fix the highlighted areas below before submitting.

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 admissions@connellycenter.org or mailing to

If you have questions, please contact admissions@connellycenter.org.