Dunlap Adventist Christian School

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Application
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Dunlap Adventist Christian School Registration Application
 
Pupils Legal Name _____________________________________    Sex:   F ___   M ___
                                 Last                                      First                                     Middle
Date of Birth ________________   Place of Birth ______________________
                                      Mo.   Da. Yr.                                                                                                                    State
Address ________________________________________________________________
                         No.            Street                                                 City                  Zip
Home Telephone   ______________________        Grade entering ____________
e-mail address ___________________________________
 
Family Information
Father
Mother
Guardian
Legal Name
 
 
 
Check One
Natural ___     Step ___     
Natural ___    Step ___
Relation
Home Address
 
 
 
Home Telephone
 
 
 
Occupation
 
 
 
Education
 
 
 
Business Address
 
 
 
Business Phone
 
 
 
Birth Date
 
 
 
Birth Place
 
 
 
US Citizen
Yes___ No___
Yes___ No___
Yes___ No___
SDA Member
Yes___ No___
Yes___ No___
Yes___ No___
Marital Status
Married___ Divorced __
Married___ Divorced __
Married___ Divorced __
 
Other Persons living with family __________________ Relation to Child ____________
Church child attends ____________________   Denomination _____________________
Baptism   Place: _________________ Date ________________
 
Children in family in order of birth including this child:
Names
Living at Home
Sex
Date of Birth
 
Yes ___ No ___
F ___ M ___
 
 
Yes ___ No ___
F ___ M ___
 
 
Yes ___ No ___
F ___ M ___
 
 
Yes ___ No ___
F ___ M ___
 
 
Yes ___ No ___
F ___ M ___
 
 
Transfer students:
School last attended ______________________________________________________
Address ________________________________________________________________
                                Street and Number
________________________________________________________________________
 City                                                State                                 Zip                  Phone
Grade Completed ______________________________
 
Please provide immunization records
Date of last Physical exam. ____________________
Factors which may interfere with child’s learning:Hearing ____ Sight ____ Speech ____ Malnutrition ____ Heart ____ Nervousness ____ Easy fatigue ____
Emotional problems ____ Language other than Eng. Used in home _________________
 
Person to notify in emergency other than parent:
1.______________________________________ Telephone _____________________
2. ______________________________________ Telephone _____________________
Physician to call in emergency _______________________ Telephone ______________
If this physician is not available, may the school call another? Yes ____ No ____
My child will go to and from school: walk ____ family car ____ bicycle ____
Has student ever been suspended or expelled from any school? Yes ____ No ____
            If yes please explain.
 
 
 
 
 
 
 
 
 
 
 
We understand the requirements and regulations of the school and pledge our full cooperation.
Signed:
Pupil ___________________________________________   Date __________________
 
Parent of Guardian ________________________________   Date __________________