Application for Admission to Petersen Elementary

Application for Admission to Petersen Elementary
Date

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Student 1 Full Legal Name *

First Name Middle Name Last Name
Grade Entering *
Sex *
Birthday *

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Date Baptized in SDA Church

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Place of Birth *
Ethnic Origin *
Religious Preference *
Student 2 Full Legal Name

First Name Middle Name Last Name
Grade Entering
Sex
Birthday

Month Day Year Date Picker Icon
Date Baptized in SDA Church

Month Day Year Date Picker Icon
Place of Birth
Ethnic Origin
Religious Preference
Student 3 Full Legal Name

First Name Middle Name Last Name
Grade Entering
Sex
Birthday

Month Day Year Date Picker Icon
Date Baptized in SDA Church

Month Day Year Date Picker Icon
Place of Birth
Ethnic Origin
Religious Preference
Student's Full Legal Name

First Name Middle Name Last Name
Grade Entering
Sex
Birthday

Month Day Year Date Picker Icon
Date Baptized in SDA Church

Month Day Year Date Picker Icon
Place of Birth
Ethnic Origin
Religious Preference
Legal name of parent or guardian with whom pupil is living
Father *

First Name Last Name
Home Phone *

Area Code Phone Number
Cell Phone Number

Area Code Phone Number
E-mail *
Religious Preference
Occupation
Mother

First Name Last Name
Home Phone

Area Code Phone Number
Cell Phone Number

Area Code Phone Number
E-mail
Occupation
Religious Preference
Church Membership

Address *

Street Address
Street Address Line 2
City	State
Zip Code	Country

Other household to communicate with
Name

First Name Last Name
Home Phone

Area Code Phone Number
Cell Phone Number

Area Code Phone Number
E-mail
Occupation

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Phone Number

Area Code Phone Number
Cell Phone Number

Area Code Phone Number
Doctor's Name

First Name Last Name
Doctor's Phone Number

Area Code Phone Number

Doctor's Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Alternate Contact

First Name Last Name
Phone Number

Area Code Phone Number

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

1. I agree to see that my student's tuition is cared for monthy.
2. I agree to cooperate with the school board and teachers by avoiding adverse criticism of any teacher or school policies in the presence of students.
3. I have read the school policy book and agree to support each regulation of the school, written and oral.
4. I hereby authorize the school to send, upon request, the permanetn records to the next school to which my child may enroll.
_____________________________________________________________

Signature of Parent or Guardian for the above statements
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