Application for Admission to Petersen Elementary

Application for Admission to Petersen Elementary
Date

MonthDayYear
Student 1 Full Legal Name*

First NameMiddle NameLast Name
Grade Entering*
Sex*
Birthday*

MonthDayYear
Date Baptized in SDA Church

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

First NameMiddle NameLast Name
Grade Entering
Sex
Birthday

MonthDayYear
Date Baptized in SDA Church

MonthDayYear
Place of Birth
Ethnic Origin
Religious Preference
Student 3 Full Legal Name

First NameMiddle NameLast Name
Grade Entering
Sex
Birthday

MonthDayYear
Date Baptized in SDA Church

MonthDayYear
Place of Birth
Ethnic Origin
Religious Preference
Student's Full Legal Name

First NameMiddle NameLast Name
Grade Entering
Sex
Birthday

MonthDayYear
Date Baptized in SDA Church

MonthDayYear
Place of Birth
Ethnic Origin
Religious Preference
Legal name of parent or guardian with whom pupil is living
Father*

First NameLast Name
Home Phone*

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
E-mail*
Religious Preference
Occupation
Mother

First NameLast Name
Home Phone

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
E-mail
Occupation
Religious Preference
Church Membership
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Other household to communicate with
Name

First NameLast Name
Home Phone

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
E-mail
Occupation
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Doctor's Name

First NameLast Name
Doctor's Phone Number

Area CodePhone Number
Doctor's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Alternate Contact

First NameLast Name
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
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
Should be Empty: