NEW STUDENT APPLICATION

Middletown Christian School of Seventh-day Adventists

70 Highland Avenue Middletown, NY 10940 (845) 343-3775
NEW STUDENT APPLICATION FORM
Date:

Month Day Year
Date
STUDENT INFORMATION
NAME

First Name Middle Name
LAST NAME
AGE
DATE OF BIRTH

Month Day Year
Date
PLACE OF BIRTH
GRADE NEXT SCHOOL YEAR
HOME ADDRESS
CITY
STATE
ZIP
HOME PHONE
PARENT'S EMAIL ADDRESS
example@example.com
CHURCH AFFILIATION
DATE BAPTIZED (If applicable)

Month Day Year
Date
SCHOOL LAST ATTENDED
SCHOOL'S ADDRESS
GRADE LAST COMPLETED
NUMBER OF SIBILINGS
FAMILY INFORMATION

STUDENT'S MOTHER
NAME
OCCUPATION
CELL PHONE #
BIRTHPLACE
NATIONALITY
EDUCATION ATTAINMENT
MARITAL STATUS
FAMILY INFORMATION

STUDENT'S FATHER
NAME
OCCUPATION
CELL PHONE #
BIRTHPLACE
NATIONALITY
EDUCATION ATTAINMENT
MARITAL STATUS
PARENT'S CHURCH AFFILIATION
STUDENT'S ADDITIONAL INFORMATION
NAME OF PRIMARY PHYSICIAN
PRIMARY PHYSICIAN'S PHONE #
IN CASE OF EMERGENCY CALL (NAME)
EMERGENCY CONTACT PHONE #
STUDENT'S SOCIAL SECURITY NUMBER
SCHOOL DISTRICT IN WHICH STUDENT IS LIVING
PLEASE LIST THREE REFERENCES BELOW WHO ARE ACQUAINTED WITH YOU AND YOUR CHILD. (PLEASE INCLUDE A TEACHER, PRINCIPAL OR PASTOR)
Reference 1
Reference 2
Reference 3
Please note: All applications are subject to approval of the MIddletown Christian School of Seventh-Day Adventists Board
WE UNDERSTAND THE OBJECTIVES AND REGULATIONS OF THE SCHOOL AND PLEDGE OUR FULL SUPPORT.
PARENT'S SIGNATURE

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NEW STUDENT APPLICATION FORM