School Application

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STUDENT INFORMATION

First Name*

Middle Name*

Last Name*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth*

Birthplace*

Country of Citizenship*

Home Number*

Mobile Number*

Social Security #*

Grade Entering*

Gender*

Female

Male

Church Student Attends*

Church Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Denomination*

Baptized*

Yes

If Yes, Date of Baptism*

Racial/Ethnic Group: (For statistical purposes)*

Primary Language*

Previous School Attended*

Number of Years Attended*

Grades Completed*

FAMILY INFORMATION

Marital Status of Natural Parents*

Who has legal custody of Student?*

If you responded Other, state who or write your name(s).*

Mother/Guardian First Name*

Mother/Guardian Middle Name

Mother/Guardian Last Name*

Mother/Guardian Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mobile Phone*

Home Phone*

Work Phone*

Email*

Social Security Number*

Occupation*

Company Name*

Company Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

U.S. Citizen*

Baptized Seventh-day Adventist

Church Membership*

Church Attending*

Father/Guardian Name*

Father/Guardian Middle Name

Father/Guardian Last Name*

Father/Guardian Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mobile Phone*

Home Phone*

Work Phone*

Email*

Social Security Number*

Occupation*

Company Name*

Company Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

U.S. Citizen*

Baptized Seventh-day Adventist*

Church Membership*

Church Attending*

EMERGENCY CONTACT INFORMATION

Student's Name*

School District*

NAD ID#

Authorized Emergency Contacts

Contact Name 1*

First Last

Relationship*

Mobile Phone*

Home Phone*

Work Phone*

Authorized to Contact*

Authorized to Pick Up*

Contact Name 2*

Relationship*

Mobile Phone*

Home Phone*

Work Phone*

Authorized to Contact*

Authorized to Pick Up*

Contact Name 3*

Relationship*

Mobile Phone*

Home Phone*

Work Phone*

Authorized to Contact

Authorized to Pick Up

STUDENT EDUCATION AND HEALTH INFORMATION

Does student have any health conditions that would limit his/her participation in any activities? If yes, explain.*

Has student received any special services, special placement and/or an IEP? If yes, explain.*

Has student ever been suspended or dismissed from any school? If yes, explain.*

Has student ever been evaluated for educational, learning, behavioral, or psychiatric reasons? If yes, please explain. Include Doctor's Name and Phone. Date of Evaluation. Any medication prescribed. (Please note: Withholding or omitting information may result in the dismissal of student.)*

Request for Records*

Yes, I authorize SBJA to request records. (Yes, even if you are a returning family.)

No, I do not authorize SBJA to request records.

References

Reference 1*

Reference 2*

Reference 3*

AGREEMENT -I hereby submit this application for admission of my child to South Bay Junior Academy of Seventh-day Adventists and have truthfully answered all questions. I understand my child is not enrolled or guaranteed placement, until accepted by the admissions committee. By signing this application form, you are indicating that you agree to abide by the following: • The rules and regulations of the school. • The school's internet and equipment user policy. • To give the school permission to use your child's picture and class work on the school's website, the Atlantic Union Conference – Gleaner and other school and conference related publications. • To participate actively in the schools' fundraisers.• To take an active part in my child's school activities including attendance and any extracurriculars; to make on time tuition payments to avoid any interruption in my child's schooling.

I have read the Agreement and agree to abide by the Agreement.*

I have read and agree.

Electronic Signature of Parent or Guardian*

Date*

School Application