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 Application HIGHLAND ADVENTIST SCHOOL Application Form Student personal information Application date__________________________ Phone______________________________ Student Name____________________________Birthdate____________________________ Physical Address_____________________________________________________________ Mailing Address (if different)___________________________________________________ Student Nickname (if any)__________________ Religious preference___________________ Name of parent or legal guardian________________________________________________ Address (if different from student)_________________________Phone_________________ Please list all other immediate family members in household with student: NAME AGE RELATIONSHIP (sister, etc.) _________________________________ ________ ____________________________ _________________________________ ________ ____________________________ _________________________________ ________ ____________________________ Please give us names of three people we may contact for a personal reference. Please do not include relatives on this list. NAME ADDRESS RELATIONSHIP PHONE TO STUDENT _________________ ____________________________ _____________ ___________ _________________ ____________________________ _____________ ___________ _________________ ____________________________ _____________ ___________ Student academic information Previous schools attended: SCHOOL ADDRESS YEARS GRADE ATTENDED COMPLETED _________________ ____________________________ _____________ ___________ _________________ ____________________________ _____________ ___________ _________________ ____________________________ _____________ ___________ Do you have any of the following on file at any school: ____ IEP* ____Behavior Plan* Have you ever been expelled from school?* Yes / No Suspended* Yes / No *If yes to any of these questions, please explain on another sheet of paper and attach. Name of previous school year's classroom teacher**________________________________ Address__________________________ Home Phone_______________________________ **We contact the previous teacher for reference and placement information. If this is a problem, please speak with your interviewer about it. Other student information Please describe any special physical, emotional, or educational needs of the student. __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ Hobbies or other interests of this student__________________________________________ __________________________________________________________________________ Please describe your reason for seeking placement for this student in Highland Adventist School_____________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ "I have read and agree to abide by the principles and governing regulations outlined in the Highland Adventist School handbook. I further agree to invest the time and energy necessary to meet the academic requirements of the school, and to support the program and philosophy of Highland Adventist School." ____________________________________ ____________________________________ Student Signature Parent/Guardian Signature ____________________________________ ____________________________________ Date Date Please complete the following release form that we will copy and use to obtain your child's records from his previous school. Only a copy of the information below will be seen by the school, not the entire application blank. Thank you. RECORD RELEASE AUTHORIZATION Date request sent______________________ Please release all pertinent scholastic and health records for the following student to Highland Adventist School, #1 Old Leadsville Road, Elkins, WV 26241. Phone 304-636-4274. Thanks! Student name________________________________ Birthdate_______________________ Dates of attendance at your school_______________________________________________ Parent Signature______________________________ Date___________________________
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