School Application : South Bay Junior Academy Babylon NY

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School Application

STUDENT INFORMATION

First Name

Middle Name

Last Name

Address

Date of Birth

Birthplace

Country of Citizenship

Home Number

Mobile Number

Social Security #

Grade Entering

Gender

Female Male

Church Student Attends

Church Address

Denomination

Baptized

Yes No

If Yes, Date of Baptism

Racial/Ethnic Group: (For statistical purposes)

Primary Language

Previous School Attended

Number of Years Attended

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

Mobile Phone

Home Phone

Work Phone

Social Security Number

Occupation

Company Name

Company Address

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

Mobile Phone

Home Phone

Work Phone

Social Security Number

Occupation

Company Name

Company Address

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

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