Bellesini Academy Admissions Application in English

1

Student's Name* This field is required.

First Name

Middle Initial

Last Name

2

Birth Date* This field is required.

3

Grade Applying For* This field is required.

4

Age* This field is required.

5

Gender* This field is required.

Male

Female

7

Place of Birth* This field is required.

City, State, Country

8

Student Lives With* This field is required.

Name, Relation

9

Present School* This field is required.

10

Present Grade* This field is required.

Grade

11

Address * This field is required.Where Student Resides

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

12

School(s) Attended* This field is required.1st Grade

13

School(s) Attended* This field is required.2nd Grade

14

School(s) Attended* This field is required.3rd Grade

15

School(s) Attended* This field is required.4th Grade

16

School(s) Attended5th Grade

If student has not yet attended 5th grade, type N/A

17

School(s) Attended6th Grade

If student has not yet attended 6th grade, type N/A

18

Has the student ever repeated a grade* This field is required.

YesNo

19

Has the student ever been evaluated for a learning disability?* This field is required.

YesNo

20

Does the student currently have an IEP (Individualized Education Program) or a 504 Plan?* This field is required.

YesNo

21

Is the student presently enrolled in any type of special education program at the school he/she attends?* This field is required.

YesNo

22

Mother's Name* This field is required.

First Name

Last Name

23

Mother's Employment Information

Occupation

Job Title

Employer

Work Phone Number

24

Mother's Cell Number

Area Code

Phone Number

25

Mother's Home Phone Number

Area Code

Phone Number

26

Mother's Email

example@example.com

27

Mother's Marital Status

Select One

28

Father's Name* This field is required.

First Name

Last Name

29

Father's Employment Information

Occupation

Job Title

Employer

Work Phone Number

30

Father's Cell Phone

Area Code

Phone Number

31

Father's Home Phone Number

Area Code

Phone Number

32

Father's Email

example@example.com

33

Father's Marital Status

Select One

34

Are any other adults, besides the mother and father, active in the child's life or living in the same household as the child?* This field is required.This includes step-parents, partners of parents, and any adult (including grandparents, aunts/uncles, cousins, or siblings 18+) who lives in the same household as the child.

YesNo

35

Other Adult in Your Child's Life #1Please list all other adults who have an active role in your child's life. Be sure to include ANY ADULT who lives in the same residence as your child.

Full Name

Relationship to Child

Does this person live with your child?

Occupation, Job Title, Employer

Email Address

Phone Number

36

Are any other adults, besides those already listed, active in the child's life or living in the same household as the child?This includes step-parents, partners of parents, and any adult who lives in the same household as the child.

YesNo

37

Other Adult in Your Child's Life #2Please list all other adults who have an active role in your child's life. Be sure to include ANY ADULT who lives in the same residence as your child.

Full Name

Relationship to Child

Does this person live with your child?

Occupation, Job Title, Employer

Email Address

Phone Number

38

Are any other adults, besides those already listed, active in the child's life or living in the same household as the child?This includes step-parents, partners of parents, and any adult (including grandparents, aunts/uncles, cousins, or siblings 18+) who lives in the same household as the child.

YesNo

39

Other Adult in Your Child's Life #3Please list all other adults who have an active role in your child's life. Be sure to include ANY ADULT who lives in the same residence as your child.

Full Name

Relationship to Child

Does this person live with your child?

Occupation, Job Title, Employer

Email Address

Phone Number

40

List all Adults Who Live with the Child (full or part-time)

Name, Relationship to Child

41

Brothers & Sisters of Child Who Reside with the ChildList all brothers, sisters, half-siblings, step-siblings who live in the same household as the child

Name

Age

Name

Age

Name

Age

Name

Age

42

Brothers & Sisters of Child Who Do NOT Reside with the ChildList all brothers, sisters, half-siblings, step-siblings who do NOT live in the same household as the child

Name

Age

Name

Age

Name

Age

Name

Age

43

Child's Religion/Place of Worship

Religion/Denomination

Place of Worship (Parish or Church)

44

Languages SpokenPlease list all languages spoken in the child's home

Primary Language Spoken at Home

Other Language Spoken at Home

45

Do you need language translation services?* This field is required.

YesNo

46

How did you hear about Bellesini Academy?* This field is required.

47

Bellesini Referral Program: Please list any names of current or alumni students that attend Bellesini Academy.

48

Does the student qualify for Free/Reduced Price Lunch?* This field is required.

YesNo

49

Annual Household Income* This field is required.

50

Number of Adults in Household* This field is required.

51

Number of Children in Household* This field is required.

52

Do you rent or own your home?* This field is required.

53

What is your monthly rent or mortgage payment?* This field is required.

54

Please describe your child (character, personality, interests, talents)* This field is required.

55

Please list activities that your child enjoys or is currently involved in at school or outside of school* This field is required.

56

Why you would like your child to attend Bellesini Academy?

57

Email Address of Person Completing This Form* This field is required.A copy of this application will be sent to this email address

example@example.com

58

Completed applications include 2020 Federal Taxes, Most Recent Report Card and Recent Utility bill. Please email to admissions@bellesiniacademy.org

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59

Please verify that you are human* This field is required.