Mansfield Seventh-Day Adventist School

   
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Application
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Mansfield Seventh-day Adventist School Application

 

STUDENT INFORMATION

 

Date of Application  ______________________      for School Year  ________________

 

 

Applying for (Circle One)      Kindergarten          Elementary   (Grade 1  2  3  4  5  6  7  8)

 

 

Student’s Legal Name  _____________________________________________________

                                                Last                             First                             Middle

 

Mailing Address

 

________________________________________________________________________

Street                          

 

________________________            ________________________            ____________

City                                                     State                                                    Zip Code

 

 

Date of Birth   ________________________      Age ________        ÿ  Male  ÿ  Female

 

 

Place of Birth (City & State)  ___________________________________  

 

 

Family’s Church Affiliation   ___________________________________

 

Is the student a baptized member of the Seventh-day Adventist Church?  ÿ  Yes ÿ  No

 

                        Date of Baptism (if baptized)   ___________________________________

 

Condition of Health:               ÿ  Excellent                ÿ  Good         ÿ  Poor

 

 

Has the student used any of the following within the past year? 

            ÿ  Alcohol                  ÿ  Tobacco                 ÿ  Controlled Substances

 

 

 

 

Name, address, and telephone of previous school (school where records would be requested):

 

________________________________________________________________________

 

________________________________________________________________________

 

 

Reason for changing schools _______________________________________________

 

________________________________________________________________________

 

 

Has the student been under any serious discipline measures during the past year?

(i.e. suspended, expelled, etc.)            ÿ  Yes                ÿ  No

 

If yes, please explain:  _____________________________________________________

 

______________________________________________________________________

 

 

 

Has the student received small group instruction assistance, LD remedial tutoring, supplemental support services)?    ÿ  Yes                ÿ  No

 

If yes, in what areas was he/she tutored?  ______________________________________

 

_______________________________________________________________________

 

Has the student ever had an IEP?  ÿ  Yes         ÿ  No

 

 

 

Is there anything special that we should know about your child’s situation

(i.e. learning, physical and emotional needs)?

 

________________________________________________________________________

 

________________________________________________________________________

 

________________________________________________________________________

 

 

 

 

Mansfield Seventh-day Adventist School Application

 

FAMILY INFORMATION

 

 

 

Father/Legal Guardian

Mother/Legal Guardian

 

Name

 

 

 

 

Home Address

(if different from above)

 

 

 

 

Home Telephone

 

 

 

 

Cell Phone

 

 

 

 

Occupation

 

 

 

 

Business

Telephone & Extension

 

 

 

 

Church Membership:

(If any)

Denomination/City/Church

 

 

 

 

Family Physician

Name and Phone Number

 

 

 

 

 

If parent(s) or legal guardian(s) cannot be reached in an emergency, please notify:

 

__________________________________          _________________________________

Name                                                                      Relationship to Student

 

Telephone  (_____)_____________________________ 

REFERENCES

(Required)

 

If applying to MSDA for the first time, please provide three recommendations on the form provided.  At least one recommendation must be from a teacher, counselor, or administrator from the most recent school attended:

 

 

1.         ______________________________

            Name

 

            ______________________________

            Relationship to Student/Family

 

            (_____)________________________           

            Telephone

 

 

 

 

2.         ______________________________

            Name

 

            ______________________________

            Relationship to Student/Family

 

            (_____)________________________           

            Telephone

 

 

 

 

3.         ______________________________

            Name

 

            ______________________________

            Relationship to Student/Family

 

            (_____)________________________           

            Telephone

 

 

 

APPLICATION AGREEMENT

 

 

·          We hereby certify that we have read the information contained in this         application, and to the best of our knowledge, the answers given are correct. 

 

·          We are acquainted with the philosophy and regulations of the Mansfield

            Seventh-day Adventist School and agree to support them while enrolled at the      school. 

 

·          We also agree to participate in school sponsored activities which may occur            outside of regular school time.

 

·          We understand that it is the policy of the school that no transcripts or credit for     work done will be issued until the school account with MSDA is paid in full.

 

_______________________________________                  _______________________

Father/Guardian Signature                                                      Date

 

 

_______________________________________                  _______________________

Mother/Guardian Signature                                                    Date

 

 

 

Please return the entire application to Mansfield Seventh-day Adventist School as soon as possible.  Final acceptance for the applicant cannot be completed until the information has been received and the recommendations have been checked.  Thank you!

 

 

 

 

MANSFIELD SEVENTH-DAY ADVENTIST SCHOOL 

1040 West Cook Road  ·  Mansfield, Ohio 44906

(419) 756-9947


 

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