JESM SDA Application

STUDENT INFORMATION

School Year School Year2020-20212021-2022

Entering Grade

Student Gender Student Gender Male Female

Student Legal First Name

Student Legal Middle Name

Student Legal Last Name

Nickname

Street Address

Apt

City

State

Zip Code

Country

Date of Birth

Age

Place of Birth

Home Phone Number

Email Address

Is child a baptized SDA? Is child a baptized SDA? Yes No

If yes, please give date

Church Affiliation

School Child Last Attended

School Address

City

State

Zip Code

School Phone Number

If applicable during the year, date of withdrawal

Reason

Has the student ever been suspended or expelled from any school? Has the student ever been suspended or expelled 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

US Citizen? US Citizen? Yes No

Address (if different from student)

Phone (if different from student)

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

Address (if different from student)

Phone (if different from student)

Occupation

Cell Phone

Work Phone

MEDICAL/EMERGENCY RELEASE INFORMATION

Parent/Guardian Legal 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 1 Phone Number

Alternate Number

Emergency Contact 2 Name

Relationship to Child/Children

Emergency Contact 2 Phone Number

Alternative Number

Physician Name

Address

Physician Contact Number 1

Physician Contact Number 2

Dentist Name

Address

Dentist Contact Number 1

Dentist Contact Number 2