Enrollment Application

Enrollment Application
School Year
Date

MonthDayYear
Student Information

Section 1 of 6
Full Name

First NameMiddle NameLast Name
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birth Date

MonthDayYear
Gender

MaleFemale
Last School Attended
Address
Last Grade Completed
Family Information

Section 2 of 6
Father's Name

First NameLast Name
E-mail
Employment
Business Phone

Area CodePhone Number
Mother's Name

First NameLast Name
E-mail
Employment
Business Phone

Area CodePhone Number
Emergency Contact Number (other than those already listed)

Area CodePhone Number
Marital Status
List of school age children in family that are not applying (Name & Age)
Reason for not applying:
Religious Information

Section 3 of 6
Church Attending
Phone Number

Area CodePhone Number
Pastor
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Are parents Bible believing Christians?
Father

YesNo
Mother

YesNo
Has applicant ever made a profession of faith in Christ?

YesNo
Medical Information

Section 4 of 6
Family Physician
Phone Number

Area CodePhone Number
Does student have any physical defects or allergies?

YesNo
If yes, explain:
Has student received immunizations?

DTP/DTaP/DT/TdPolioVaricellaMMRHepatitis B
Scholastic Information

Section 5 of 6
Has student ever been expelled, dismissed, suspended, or refused admission to another school?

NoYes
If yes, explain:
Has student ever had disciplinary difficulty at school?

NoYes
If yes, explain:
Does student have a juvenile or arrest record?

NoYes
If yes, explain:
Has student ever used tobacco or nonprescription drugs of any kind?

NoYes
If yes, explain:
Has student ever failed an academic subject in school?

NoYes
If yes, explain:
Please indicate academic level of student's previous work:

ExcellentGoodAverageFairPoor
General Information

Section 6 of 6
How did you hear about Gateway?
Reason for selecting Gateway?
Application must be filled out completely before it can be processed.

An interview with the parents and the student will be required before final acceptance. An application, registration, and testing fee of $150 is due at time of enrollment and is not refundable.
Should be Empty:

Enrollment Application

Student Information

Family Information

Religious Information

Medical Information

Scholastic Information

General Information