Student Application Form
Application Fee : $250.00 Per Student
Student Information
First
Middle
Last
Gender
Male
Female
Birth Date (dd/mm/yyyy)
/
Month
/
Day
Year
Date
MCP #
Entering Grade
Address
Home Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address
Same as above or
Other
Family Information
Home Phone
Primary Email
example@example.com
Is English your first language
Yes
No*
If No, Please Specify
Mother/Guardian
Employer
Work phone
Email
example@example.com
Lives with child
Yes
No
Father/Guardian
Cell Phone
Employer
Work phone
Email
example@example.com
Lives with child
Yes
No
Do you have other children in grades K-12 enrolled elsewhere?
Yes
No
Do you have other children under 5 years old?Yes
Yes
No
* Please list other children's names below and state what school they attend (if applicable)
Name
Birth Date
/
Month
/
Day
Year
Date
Name
Birth Date
/
Month
/
Day
Year
Date
Name
Birth Date
/
Month
/
Day
Year
Date
Church Information
Church attending (If applicable)
Church Address
Academic Information
Please include a copy of your child's most recent report card.
School Last attended (if applicable)
Grades completed at the last school listed above
Have your child ever had any discipline problems at school?
Yes
No
If yes, please explain:
Are there any special accommodations your child might require?
Yes
No
If yes, please explain:
Does your child have any learning disabilities?
Yes
No
If yes, Please explain:
Are there any other areas of concern of which we should be aware of?
Health Information
Family Physician
Phone
MCP #
Expiry Date
/
Month
/
Day
Year
Date
Please list any allergies your child may have (please specify any food allergies clearly)
Does your child require any EpiPen or other allergy medication?
Yes
No
Does your child currently take any medication on a regular basis?
Yes
No
If yes, please provide details
Are there any other medical conditions we should be aware of?
Emergency Contact *When parents/guardians are unavailable
Name
Phone
Address
Relationship
Parents Signature
Date
/
Month
/
Day
Year
Date
Parents Signature
Date
/
Month
/
Day
Year
Date
References
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