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Application for Admission 2014-15 Due at or prior to your admission testing date

PLEASE PRINT STUDENT INFORMATION

Last Name

First Name

Middle Name

Check here if you are NOT a US citizen.

Gender

Male

Female

Social Security Number

Age

Date of Birth

Present Grade Level

Applying for Grade

Address (Street Number and Name)

Apt. #

City

State

Home Phone

Zip Code

Parent/Guardian Phone

Student Cell Phone

Parent E-mail

PARENT/GUARDIAN INFORMATION

Parent/Guardian Name

Relationship to Student

Contact Number

Parent/Guardian Name

Relationship to Student

Contact Number

Check all that apply:

Student Lives with:

Estimated Annual Family Income* Include child support, Social Security benefits, etc.

Mother

Father

Total Number of People Living in the Home

How did you hear about Chinquapin (Parent/Guardian)?

Other

*Please attach a copy of your most recent Federal Income Tax Return (1040, 1040A)


SCHOOL INFORMATION What are your grades in the following subjects? School Currently Attending

English

Math

Social Studies

Science

Reading

Conduct

Number of Days Absent Electives (include grade received)

If absent more than 10 days, please explain:

Have you applied to or attended Chinquapin before?

Yes

No

When?

Are you related to a Chinquapin student or graduate?

Yes

No

Who?

Have you ever been suspended or expelled from school?

Yes

No

Do you have any allergies?

Yes

No

Do you use an EPI Pen?

Yes

No

Are you or have you been on probation?

Yes

No

If you answered yes to any of the questions above, please explain.

Parent Signature

TO BE COMPLETED BY THE STUDENT: Answer, in essay form, the following questions: 1. How did you hear about Chinquapin?

2. What are your reasons for wanting to come to Chinquapin?

Date

What?


Student Signature

Date

[Title will be auto-generated]  

http://www.chinquapin.org/website/images/docs/2014-2015_Application.pdf

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