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Student Application
Bethel Adventist
®
Church School
"Under His Wings"
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Student Application
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Student Application
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