Currently, students in the following ASD-zoned schools are eligible for enrollment at GRAD Academy Memphis:

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1 GRAD Academies, a division of Project GRAD USA, are New Tech Network High Schools, which anchor student learning in a project based, technology enriched curriculum. Teachers act as coaches, guides, and facilitators and to lead students to build authentic and meaningful projects tied to state and national Common Core Standards. ABOUT GRAD ACADEMY MEMPHIS The mission of GRAD Academy Memphis is to provide all students in an open-enrollment high school with an outstanding 21 st century education, to prepare them for college and career success, and to inspire them to be engaged participants in our democracy. It is the first GRAD Academy High School in the nation, and employs a new design that joins the highly successful New Tech Network (NTN) high school learning and development platform with the proven, comprehensive wraparound supports and college readiness strategies of Project GRAD USA (GRAD) as well as several high tech adaptive learning and data management support elements. GRAD Academy Memphis is designed on a computer integrated, project based learning model, with a STEAM (Science, Technology, Engineering, Arts, and Mathematics) curricular focus, complemented by an aggressive focus on closing skill and achievement gaps, especially in literacy and mathematics. Students work in teams and focus on real-world problems. ENROLLMENT GUIDELINES & REQUIREMENTS GRAD Academy Memphis is an open enrollment high school that is part of the Achievement School District (ASD) of Tennessee, an innovative statewide district that works to move the bottom five percent of schools in Tennessee to the top twenty-five within five years. Our school is fully aligned with Tennessee and national Common Core Standards. Currently, students in the following ASD-zoned schools are eligible for enrollment at GRAD Academy Memphis: Chickasaw Middle School City University Middle School Hamilton Middle School Lester Middle School Riverview Middle School Southside Middle School 1

2 STUDENT ENROLLMENT FORM SECTION 1: STUDENT INFORMATION (please print) First name M.I. Last name Street Address City State Zip code _ Date of Birth (mm/dd/year) Age Gender (Male, Female) African American/Caucasian/Hispanic/Asian/Other: - - Race (Circle One) (specify) Social Security Number Current Grade Current School Allergies or Dietary Restrictions (please list all): SECTION II: PARENT/GUARDIAN INFORMATION (please print) PARENT/GUARDIAN # 1 First name M.I. Last name Street Address City State Zip code Phone (primary # or preferred contact #) PARENT/GUARDIAN #2 2

3 First name M.I. Last name Street Address City State Zip code Phone (primary # or preferred contact #) SECTION III: BACKGROUND INFORMATION Does your child reside with the parents/guardians named on this enrollment form? Yes No If no, please clarify: Do you have other children who will be entering high school within the next four years? Yes No How did you hear about GRAD Academy Memphis? Friend or colleague GRAD Academy Memphis website Internet or social media - Please list: Current Scholar and/or Parent - Please name: GRAD Academy Memphis Faculty Member - Please name: Print/radio/television advertisement Public or community event SECTION IV: HEALTH INFORMATION Does your child have a medical condition that may affect his or her school day? 3

4 YES NO If YES, please describe here: Allergies Type of Allergy (please mark all that may apply) Food Medications Bee Sting Other List Foods: List Medications: List: Allergic Reactions (please mark all that may apply) Coughing Generalized swelling Wheezing Rash Local swelling Nausea Difficulty Breathing Hives Other List: Current Medications (please list all) Food Restrictions (please list all that may apply or indicate none by writing N/A) Due to Gastrointestinal Intolerance Due to Religious Reasons Immunizations Are all of the immunizations for your GRAD Academy Scholar up to date for the upcoming school year? YES NO 4

5 Health Insurance Information Name Name of Insured: Name Name of Insurer: Insurer Insurer s Phone Number: Insurer Insurer s Address List 3 Emergency Contacts (1) Name: Phone: (2) Name: Phone: (3) Name: Phone: By signing below, you indicate that all information included on this student enrollment form for GRAD Academy Memphis is accurate and specified to the best of your knowledge. PARENT/GUARDIAN SIGNATURE DATE INSTRUCTIONS FOR SUBMITTING ENROLLMENT FORM 5

6 IN PERSON OR BY MAIL: GRAD Academy Memphis Attn: Admissions & Enrollment 1880 Prospect St. Memphis, TN VIA Nicole Dobbs QUESTIONS? For more information or for questions regarding student enrollment at GRAD Academy Memphis, please contact Ashley Lynch at (901) or THANK YOU. FOR OFFICE USE ONLY Date Received: Time Received: Delivery Method: Mail Fax In person Received by: Eligible for Enrollment: Notes: 6