Black Mountain Science Academy Application for Admission

Application for Admission
Date

MonthDayYear
Date
Child’s Name
Date of Birth

MonthDayYear
Date
MaleFemale
Primary Address
Home Phone
Sibling Information: Name and Ages
Parent Information
Father’s Name
Email Address
example@example.com
Home Address
Home Phone
Cell Phone
Occupation
Work Phone
Work Address
Mother’s Name
Email Address
example@example.com
Home Address
Home Phone
Cell Phone
Occupation
Work Phone
Work Address
Are both parents living?

YesNo
If so, marital status of parents:

MarriedSeparatedDivorced
If separated or divorced, who has custody of child?
Does your child have an IEP or MET?

YesNo
If yes, please explain:
Reason for leaving previous school/child care
Application for Admission to:
Select Program

Preschool 5 Half Days (Ages 3-5 Mon - Fri 8:30 - 11:30AM)Preschool 5 Full Days (Ages 3-5 Mon - Fri 8:30 - 3:30PM)Kindergarten (Ages 5-6 Mon - Fri 8:30 - 3:30PM)Elementary (Ages 6-12 Mon - Fri 8:00 - 3:30PM)
A $250 nonrefundable application fee must accompany this application.
Signature of Parent/Guardian

Clear
Mail the Application form and Fee to: Director of Admissions, Black Mountain Science Academy 8977 W. Athens St. Peoria, AZ 85382
Contract

Cancelof
Should be Empty:

Application for Admission