STUDENT INFORMATION
Term Date
Last Name First Name Middle Address City State ZIP Telephone# Age Sex Birth Date Birthplace
School Last Attended
Address
Last Grade Completed
Family Information
Father's Name
Employment Position
Business Phone Cell# Email
Mother's Name
Employment Position
Business Phone Cell# Email
Emergency telephone number, other than those already listed:
Marital Status: Married Divorced Widow Separated
Children in family of school age if not applying:
Name Age
Reason they are not applying:
RELIGIOUS INFORMATION
Church Attending Pastor Phone
Father: Christian? Yes No Mother: Christian? Yes No
Has applicant ever made a profession of faith in Christ? Yes No
MEDICAL INFORMATION
Family Physician Phone#
Does student have any physical defects or allergies? Yes No
If yes, please explain:
Has student received immunizations: Diphtheria Smallpox Polio
SCHOLASTIC INFORMATION
Has student ever been expelled, dismissed, suspended, or refused admission to another school? Yes No
If yes, please explain:
Has student ever had disciplinary difficulty at school? Yes No
If yes, please explain:
Does student have a juvenile or arrest record? Yes No
If yes, please explain:
Has student ever used tobacco or nonprescription drugs of any kind? Yes No
If yes, please explain:
Please indicate academic level of student's previous work: Excellent Good Average Poor
Has student ever failed an academic subject in school? Yes No
If yes, please explain:
GENERAL INFORMATION
How did you hear about this school?
Reason for selecting this school:
Application must be filled out completely before it can be processed. Application, Registration, and Testing Fees of $
must accompany Application and are not refundable. An interview with the parents and the student will be required before final
acceptance.
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