Philmore Academy Application 2022-23

NEW STUDENT APPLICATION 2022-2023
Student Legal Name *

Student First Name Student Middle Name Student Last Name Suffix
Grade Level 2022-23 *
Grade Level 2022-23
Gender *
Gender
Birth Date *

Month Day Year
Address *

Student Street Address

Student Apt #

City State / Province

Postal / Zip Code
Phone Number *

Student Area Code Student Phone Number
Parent Information
Mother/Guardian *

Mother First Name Mother Last Name
Address *

Mother Street Address

Mother Apt #

City State / Province

Postal / Zip Code
Home Phone *
Mother Home Phone
Cell Phone *
Mother Cell Phone
Email *
Mother Email
Occupation *
Mother Occupation
Father/Guardian

Father First Name Father Last Name Suffix
Address

Father Street Address

Father Apt #

City State / Province

Postal / Zip Code
Home Phone
Father Home Phone
Email
Father Email
Cell Phone
Father Cell Phone
Occupation
Father Occupation
School Information
Last School Attended *
Last Grade Completed *
Reason for Leaving *
School Address *

School Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
School Phone *
School Phone
Student Academic Performance (Current or Final) *

Excellent (All A's) Above Average (A-B) Average (B-C) Below Average (C-D) Failing (D-F) No Report Card (PreK4-K ONLY)

Current or Final Report Card (If PreK-K, please type N/A in grade box) *

	Grade
ELA/Reading
Mathematics
Science
Social Studies
PreK-K

Upload a copy of most recent report card/progress report

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Progress Report/Report Card (Required for Grades K and above) Cancel of
Has student ever repeated a grade or been dismissed from school? *
If so , please explain why
Has the applicant ever been tested or received special help for a reading or learning deficiency? *
If so, explain why.
Has the applicant ever experienced disciplinary issues, been suspended, expelled, or asked to withdraw? *
If yes, upload discipline history

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Discipline History Cancel of
In which subjects has your child excelled in previously? *
In which subjects has your child had the most difficulty previously?
Please tell us how Philmore Academy will benefit your child. *
Provide us with your personal perspective by describing your child's strengths and abilities and special areas of interest. *
List awards, scholarships, publications or special recognitions your daughter/son has received. List in descending order of significance. (If none write N/A) *
Teacher Recommendation

All applicants must provide two teacher recommendations from the most recent teacher who has taught them in the areas of English/Reading and Mathematics to share insight about your child's intellectual curiosity, creative thought, and work habits. Please provide the name and email of a teacher that can complete the recommendation form on your child's behalf. This is required for students in grades 1 and above.
School *
Recommending School
Subject Area
Teacher Subject Area
Teacher Name

Teacher First Name Teacher Last Name
Grade Level
Teacher Grade Level
Teacher Email
Teacher Email
School
Recommending School
Subject Area
Teacher Subject Area
Teacher Name

Teacher First Name Teacher Last Name
Grade Level
Student Grade Level
Teacher Email
Teacher Email
Student resides with: *
Parents are expected to contribute 5 volunteer hours per year. Will you be able to meet this requirement? *

Yes No
Signature *

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New Student Application Fee $ 50.00

Total $ 0.00

Payment Methods

Debit or Credit Card

First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Please click one of the PayPal options to complete payment and submit the form.

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NEW STUDENT APPLICATION 2022-2023

Parent Information

School Information

Teacher Recommendation