ONLINE APPLICATION FORM

Student Full Legal Name

School Year School Year2020-20212021-2022

Entering Grade

Student Gender Student Gender Male Female

First Name

Middle Name

Last Name

Nickname

Street Address

Apt

City

State

Zip Code

Country

Date of Birth

Age

Place of Birth

Social Security Number

Home Phone Number

Email Address

Is Child a Baptized SDA? Is Child a Baptized SDA? Yes No

If Yes, Please Give Date

Church Affililation

School Child Last Attended

School Address

City

State

Zip

School Phone Number

If Applicable During Year, Date of Withdrawal:

Reason

Has student ever been expelled or suspended from any school? Has student ever been expelled or suspended from any school? Yes No

If so, please explain

Family Information

Name of Mother (Full Name)

Date of Birth

Birth Place

Marital Status

Baptized SDA? Baptized SDA? Yes No

Church Membership

Years of Education

U.S. Citizen? U.S. Citizen? Yes No

Mother's Address (if different from student's)

Mother's Phone (if different from student's)

Occupation

Cell Phone

Work Phone

Name of Father (Full Name)

Date of Birth

Birth Place

Marital Status

Baptized SDA? Baptized SDA? Yes No

Church Membership

Years of Education

U.S. Citizen? U.S. Citizen? Yes No

Father's Address (if different from student's)

Father's Phone (if different from student's)

Occupation

Cell Phone

Work Phone

Medical/Emergency Release Information

Parent/Legal Guardian's Full Name

Street Address

City

State

Zip Code

Home Phone

Cell Phone

Work Phone

Ext

Child 1 Full Name

List all Known Medical Conditions, Including Food Allergies and/or Drug Allergies. In Addition, Include Any and All Over- the-Counter and/or Prescription Drugs Taken Regularly

Child 2 Full Name

List all Known Medical Conditions, Including Food Allergies and/or Drug Allergies. In Addition, Include Any and All Over- the-Counter and/or Prescription Drugs Taken Regularly

Child 3 Full Name

List all Known Medical Conditions, Including Food Allergies and/or Drug Allergies. In Addition, Include Any and All Over- the-Counter and/or Prescription Drugs Taken Regularly

Child 4 Full Name

List all Known Medical Conditions, Including Food Allergies and/or Drug Allergies. In Addition, Include Any and All Over- the-Counter and/or Prescription Drugs Taken Regularly

Emergency Contact 1 Name

Relationship to Child/Children

Emergency Contact 2 Name

Relationship to Child/Children

Physician's Name

Address

Contact Number 1

Contact Number 2

Dentist's Name

Address

Contact Number 1

Contact Number 2