School Application Form

School Application Form

Please carefully fill out this form. If any questions arise, please contact the school at (916) 652-6279 or email us office@rbcloomis.org for more information.
Student Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Age
Place of Birth
Gender

MaleFemale
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian's Information
Father's Name

First NameLast Name
Occupation
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Mother's Name

First NameLast Name
Occupation
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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.Format: (000) 000-0000.
Relation to Student
Student and Family Background
Where is your current church membership established?
Do you attend church regularly?

YesNo
Please select each of the following who has been saved and baptized.

Father (or Male Guardian)Mother (or Female Guardian)StudentNone of the Above
Has the student ever been expelled?

YesNo
If yes, please explain:
Has the student ever been retained?

YesNo
If the student has been retained, please select which grade level.
Has the student ever had any incidents with the law, or does the student have a police record?

YesNo
If the student has 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?
State the reason(s) you wish to have this student attend Regency Baptist Academy.
Reminders
TEST. The school required new students or a transferee to take an exam in order to get admitted to the school.

INTERVIEW. The school admin may 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.
Date Signed

MonthDayYear
Date
Parent/Guardian Signature
Should be Empty:

School Application Form

Parent/Guardian's Information

Student and Family Background

Reminders