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CMS Admissions Application

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.

If you prefer, you may complete the PDF application here and deliver or mail the completed application to the address below.

In addition to the application, you must supply the following documents by emailing them to trivera@connellycenter.org or mailing to:

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

Copy of student’s birth certificate
Completed 2020 tax return (form 1040) and last two pay stubs
Proof of Social Security benefits or Public Assistance (if applicable)
Her most recent report card/student academic records and state test scores (if available)

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

In response to the COVID-19 pandemic and financial challenges faced by many, CCC will be completely free (no tuition or fees) for the 2021-2022 school year. We will reassess tuition and fees in future years. Please reach out to our main office at 212.982.2287 if you have any questions or concerns about tuition or the application process.

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*

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City*

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State*

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Zip Code*

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Phone Number*

Number Required

Present School*

Answer Required

Present Grade*

Answer Required

NYC School I.D. Number

Answer Required

School History: List all the schools your student has attended. Begin with the first school they attended.

For all schools attended, provide School Name, Location, Grade(s) Attended.*

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

Bus shelter advertisement / street advertisement

Walked past our building

Heard CCC staff member speak

Saw a flier

Other:

If you learned about CCC from a student or graduate or her family, please provide their name.

Answer Required

If other, please describe.

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

Number Required

Cell Phone

Number Required

Employer

Answer Required

Occupation

Answer Required

Work Phone

Number Required

Answer Required

Father

Full Name

Answer Required

Address

Answer Required

Home Phone

Number Required

Cell Phone

Number Required

Employer

Answer Required

Occupation

Answer Required

Work Phone

Number Required

Answer Required

Guardian (if applicable)

Full Name

Answer Required

Address

Answer Required

Home Phone

Number Required

Cell Phone

Number Required

Employer

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Occupation

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Work Phone

Number Required

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

If other, please elaborate.

Answer Required

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. For this reason, we ask parents/guardians to disclose income information as part of the application process. Currently, the majority of our student body qualifies 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

Please provide the names and Social Security numbers of all parents/guardians.

Answer Required

Student Description

Why do you want your student to attend CCC?*

Answer Required

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

Answer Required

Please list any after school programs and/or weekend programs that your student participates in.*

Answer Required

How does your student usually spend her summer?*

Answer Required

Teacher Contact Information.

Please provide contact information for your student's two most recent teachers. If she is applying for 4th grade, her 2nd and 3rd grade teachers; if she is applying for 5th grade, her 3rd and 4th grade teachers.

For each teacher, provide: Teacher Name, School, Phone Number, Email Address*

Answer Required

Parent/Guardian Signature

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

I understand that CMS has a mandatory, one-week new student orientation in the summer at Cornelia Connelly Center.*

Answer Required

I understand

I understand that part of my student's acceptance is attending mandatory summer programming each year.*

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 an ICT (Special Education) class.*

Answer Required

I understand

I understand that CMS does NOT have a nurse on staff.*

Answer Required

I understand

Code of Conduct and Parental Involvement

It is my understanding that Cornelia Connelly Center - Connelly Middle School (CMS) 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

Date*

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

Date*

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.

Confirmation Email

Confirmation Email *

Enter your email address here if you'd like to receive a confirmation upon submitting the form.

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