Date of Application Student Social Security # 1. Full Legal Name of Student Checkboxes Female Male 2. Date of Birth Place of Birth Age (Choose from dropdown) -Select document submitted to verify birthdate for child entering Kindergarten or 1st grade. Birth Certificate Hospital Statement Notarized Statement Passport or Visa 3. (Choose) Dropdown - Student is living with: Father Mother Both Father and Mother Stepfather Stepmother If Other (Please Specify) Home Address City, State, Zip Code Telephone# or Cell# Email 4. Legal names of those checked in #3. Denomination affiliation of those checked in #3 Church where membership held from #3 Language used at home from #3 Occupation from #3 Is the student sponsored by an Adventist Church member? Yes No 5. Is the student a baptized member of the Adventist Church? Yes No If yes, indicate year baptized and church where membership is held 6a. School last attended, address, telephone# 6b. Reason for leaving 7. Family Physician, Address, Telephone# 8. Person to be notified in case of emergency if parent is not available 9a. Indicate physical problem by check mark Hearing Heart Speech 9b. What else should we know about your child? 10. If on regular medication, please specify 11. In the event of sudden illness or accident requiring attention, school personnel are authorized to administer first aid, and if necessary, take child for emergency treatment to a doctor's office or hospital. Hospital Preference 12. Number of other children in the family 12a. Name of 1st child Gender Male Female 12b. Name of 2nd child Gender Male Female 12c. Name of 3rd child Gender Male Female Check if siblings live with you Yes No 13. Has this student been previously identified as qualifying for a gifted education program? Yes No 13a. If yes, what kind? 13b. If you answered yes, when? 13c. Where? By Whom? 14. Has this student been previously identified qualifying for a special education program? Yes No If yes, what kind? When? Where? By Whom? Dropdown (Choose) Does student have an unpaid account at another school? Yes No If so, where? 16. Name and address of person to whom financial statements are to be sent if different from that given in item #3. Name #1 Address Telephone# Name #2 Address Telephone# 17. Name(s) and relationship of individuals authorized to pick-up your child. (Identification required at time of pickup). #2 Name and Relationship #3 Name and Relationship Dropdown (Student Contract): I agree to uphold the school's regulations. I pledge my concentration with and loyalty to the school and its employees. I will abide in harmony with the school's Christian principles. __________________________ Student's Signature __________________________ Date Dropdown (Parent Contract) I hereby agree to support school regulations and to help my child observe them, to supply physical examination repots for this student, a) entering school for the first time, b) at grade seven (this should include the scoliosis examination, c) at least once in grade 9 through 10, and d) at other grades, when required by the Conference Board of Education, and to accept all financial educational obligations for this student. ___________________________ Parent Signature ___________________________ Date Submit
