BCC 2018-2020 Application

Student's Residency Information
Are you a Florida resident: *

Yes No
If No, what state are you a resident:
With whom do you make your permanent residence:

First Name Last Name
What is your relationship:
I will be a graduate of a Lloyd Preparatory School after completing my senior year of school: *

Yes No

Disability Information

If you have a disability and may require accommodations, please submit a confidential written request for disabilities accommodations. Written documentation of the disability is required. All documentation will be confidential and used only in accordance with federal regulations; Section 504 of the Rehabilitation Act and Americans with Disabilities Act.
Safety and Security

(All applicants must answer these questions)
Have you been subjected to court-ordered confinement for threatening or causing physical or emotional injury to person or property: *

Yes No
Have you ever been disciplined, suspended from, or placed on probation at any education institution for non-academic reasons: *

Yes No
Suspension is defined as a sanction imposed for disciplinary reasons that result in a student leaving school for a fixed time period, less than permanently. Dismissal from a school for disciplinary reasons is defined as permanent separation from an institution of education based on conduct or behavior.

Academic History
Are you a first time or first year LPS student: *

Yes No
Have you attended (registered) at another school whether credit was earned or not: *

Yes No
If you have attended (registered) or are attending another school, please provide the following information for each intuition. You are required to submit an official transcript for all institutions you have attended:

Name of 1st School

City State / Province

Postal / Zip Code
Dates of attendance: Dates Difference
Address

Name of 2nd School

City State / Province

Postal / Zip Code
Dates of attendance: Dates Difference
Address

Name of 3rd School

City State / Province

Postal / Zip Code
Dates of attendance: Dates Difference
Address

Name of 4th School

Degree(s) earned

City State / Province

Postal / Zip Code
Dates of attendance: Dates Difference
Were you ever suspended or dismissed for academic reasons from any of the institutions listed above?

Yes No

Statistical Information

Providing the following information requested by this section is voluntary and the information provided is for statistical analysis only.
Number of Household Members:
Religious preference
Has either of your parents(s) or guardian(s) completed a bachelor’s degree?

Yes No Unsure

Media Release
I, the undersigned, consent and grant to Lloyd Preparatory School, and its designees all rights to use my name, portrait, picture, photograph, or likeness of same at its discretion for internal & external presentations and community development-related external promotions for LPS without further notice to me. I hereby waive any inspection or approval of any internal presentations and/or external community development-related promotions in which my name/photos appear; I release LPS from any liability for any claim of visual alteration, optical illusion, or faulty mechanical reproduction. I hereby waive all legal claims to compensation or receipt of consideration from the rights granted by this consent and further acknowledgment that this consent is valid. I have given this consent voluntarily.
Applicants complete legal signature *

Clear
Date: *
Should be Empty:

Now create your own Jotform - It's free! Create your own Jotform

Lloyd Preparatory School™