Lottery Enrollment Form

Please provide the following information:

Parent Information
Mother's First Name
Mother's Last Name
Street Address
Address (cont.)
City
State
Zip
Work Phone
Home Phone
Father's First Name
Father's Last Name
Street Address
Address (cont.)
City
State
Zip
Work Phone
Home Phone

Student Information
Student #1
First Name
Last Name
Boy/Girl	Girl Boy
Date of Birth	MM 01 02 03 04 05 06 07 08 09 10 11 12 DD 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 YYYY 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Grade for 2012—2013 school year	Kindergarten First Second Third Fourth Fifth Sixth Seventh Eighth
Current School
Student #2
First Name
Last Name
Boy/Girl	Girl Boy
Date of Birth	MM 01 02 03 04 05 06 07 08 09 10 11 12 DD 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 YYYY 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Grade for 2012—2013 school year	Kindergarten First Second Third Fourth Fifth Sixth Seventh Eighth
Current School
Student #3
First Name
Last Name
Boy/Girl	Girl Boy
Date of Birth	MM 01 02 03 04 05 06 07 08 09 10 11 12 DD 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 YYYY 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Grade for 2012—2013 school year	Kindergarten First Second Third Fourth Fifth Sixth Seventh Eighth
Current School