LifeGate Academy

LifeGate Academy

STUDENT APPLICATION FORM
Student Name

First NameLast Name
Are you applying for full time private school or homeschool?
Age
MaleFemale
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Place of Birth
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Grade Level
School Year
School Last Attended
School Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Has your student been expelled or denied admittance from another school? If yes, please explain.
Parent/Guardian's Information
Parent/Guardian's Name - Primary

First NameLast Name
Phone Number
Please enter a valid phone number.
Occupation
Parent/Guardian's Name - Secondary

First NameLast Name
Phone Number
Please enter a valid phone number.
Occupation
In case of emergency, who will be notified? Please answer the fields below:
Emergency Contact Person

First NameLast Name
Emergency Phone Number
Please enter a valid phone number.
Recommendations

Please submit a recommendation letter or bring one to your interview appointment.
Upload
Please submit at the names of at least one other person we can contact for recommendation.
Are you currently an active member of a local church congregation?
Health History
If the student have any allergies, please list them down below:
Does the student currently taking any medications? If yes, please list them down below:
Does the student have any medical conditions that you would like to declare?

Immunization/Vaccination (Optional: Provide a copy of Immunization card or a Vaccination Exemption letter upon enrollment.)

Rows	Vaccinated?	Year
BCG
Hepatitis B
Pneumococcal
HPV
Varicella
Tetanus
Meningitis
Measles
Mumps
Rubella
Rabies
Polio

Reminders
TEST. The school may required new students or a transferee to take an exam in order to get admitted to the school. INTERVIEW. The school admin will conduct an interview with the parent and/or student as part of the screening test. REQUIREMENTS. It is important to pass and complete all requirements before school starts. Failure to do so may delay the student from coming to school.
Parent/Guardian Signature

Clear
Date Signed

MonthDayYear
Date
Should be Empty:

LifeGate Academy

Parent/Guardian's Information

Recommendations

Health History

Reminders