School Application Form

School Application Form
Student Name

First NameLast Name
Age
Gender

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
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.
File Upload

2x2 Colored ID Picture, birth certificate, report card from the previous school, and medical clearance.
Upload
Authorization To Pick Up

These People listed are authorized to pick my child up
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
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:
Was the student previously hospitalized or undergo any surgerys?
Does the student have any medical conditions that you would like to declare?

Immunization/Vaccination

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

Reminders
INTERVIEW. The school admin will conduct an interview with the 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.

MEDICAL CLEARANCE. The school required all students to have a yearly physical exam. For new students, medical clearance for their doctor or school doctor is required.
Parent/Guardian Signature

Powered by Jotform SignClear
Date Signed

MonthDayYear
Date
Should be Empty:

School Application Form

Parent/Guardian's Information

File Upload

Authorization To Pick Up

Health History

Reminders