Application for Admission to Petersen Elementary

Application for Admission to Petersen Elementary
Date

- Month - Day Year
Student 1 Full Legal Name *

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

- Month - Day Year
Date Baptized in SDA Church

- Month - Day Year
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 Baptized in SDA Church

- Month - Day Year
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 Baptized in SDA Church

- Month - Day Year
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 Baptized in SDA Church

- Month - Day Year
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
Should be Empty:

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