New Student Application 2022

Middletown Christian School

New Student Application 2022 - 2023
70 Highland Avenue Middletown, NY 10940 Phone: (845) 343-3775 Fax: (845) 343-6633
STUDENT INFORMATION
FIRST NAME
MIDDLE NAME
LAST NAME
DATE OF APPLICATION

Month Day Year
Date
Address

STREET

Street Address Line 2

CITY STATE

ZIP
Parent's Email
example@example.com
HOME PHONE
STUDENT'S AGE
SEX
BIRTHDATE

Month Day Year
Date
BIRTHPLACE
SCHOOL LAST ATTENDED
SCHOOL'S ADDRESS
GRADE LAST COMPLETED
ANY PHYSICAL DISABILITIES? (SPECIFY IF YES)
NUMBER OF BROTHERS
OLDER
YOUNGER
NUMBER OF SISTERS
OLDER
YOUNGER
CHURCH AFFILIATION
DATE BAPTIZED

Month Day Year
Date
NAME OF PHYSICIAN
PHONE
IN CASE OF EMERGENCY CALL:
NAME
PHONE
CELL PHONE
STUDENT'S SOCIAL SECURITY NUMBER
SCHOOL DISTRICT IN WHICH STUDENT IS LIVING
FAMILY INFORMATION - MOTHER
MOTHER'S NAME
OCCUPATION
BUSINESS PHONE
CELL PHONE
Email
example@example.com
CHURCH AFFILIATION
BIRTHPLACE
EDUCATION ATTAINMENT
NATIONALITY
MARITAL STATUS
FAMILY INFORMATION - FATHER
FATHER'S NAME
OCCUPATION
BUSINESS PHONE
CELL PHONE
Email
example@example.com
CHURCH AFFILIATION
BIRTHPLACE
NATIONALITY
EDUCATION ATTAINMENT
MARITAL STATUS
DO YOU HAVE AN UNPAID SCHOOL ACCOUNT?
WHERE?
PLEASE LIST THREE REFERENCES BELOW WHO ARE ACQUAINTED WITH YOU AND YOUR CHILD. (PLEASE INCLUDE A TEACHER, PRINCIPAL OR PASTOR)
1. NAME
ADDRESS
2. NAME
ADDRESS
3. NAME
ADDRESS
PLEASE NOTE: ALL APPLICATIONS ARE SUBJECT TO APPROVAL OF THE MIDDLETOWN CHRISTIAN SCHOOL OF SEVENTH-DAY ADVENTISTS BOARD.

WE UNDERSTAND THE OBJECTIVES AND REGULATIONS OF THE SCHOOL AND PLEDGE OUR FULL SUPPORT.
PARENT'S SIGNATURE *

Clear
Should be Empty:

Middletown Christian School

STUDENT INFORMATION

IN CASE OF EMERGENCY CALL:

FAMILY INFORMATION - MOTHER

FAMILY INFORMATION - FATHER