Student Application : Milton-Stateline Adventist School Milton Freewater Oregon

Student Info

Student's Name

Grade

Date of Birth

Place of Birth

Age

Home Phone

Mother's Info

Name

Cell Phone

Occupation

Employer

Work Phone

Father's Info

Name

Cell Phone

Occupation

Employer

Work Phone

Addresses

Omit Mailing Address if it is the same as Physical Address.

Physical Address

Mailing Address

Non-Custodial Parent

Yes/No

Father Mother

Name

Address

Phone

Contact Allowed?

Yes No

Church Membership

Student Church Membership

Student Baptism Date

Parent Church Membership

Parent Baptized SDA?

Yes No

Contacts

Emergency Contacts must not be immediate family.

Family Doctor

Family Doctor Phone

Emergency Contact 1

Emergency Contact 1 Phone

Emergency Contact 2

Emergency Contact 2 Phone

Emergency Contact 3

Emergency Contact 3 Phone

Health Info

Please list any health concerns such as diabetes, heart disease, allergies to food/medicine/bees, current medications, or other pertinent information:

Has student been diagnosed with ADD, ADHD, Dyslexia, or other disorders?

Yes No

If Yes, please explain:

Alert

Please list any person or persons your child is NOT allowed to see or leave campus with:

Student and Parent Pledge

All students and parents read carefully and sign below. Please enter initials beneath each statement.

I have read (or parents have read to me) the rules as outlined in the MSAS handbook, and I agree to support them without grumbling or complaining.

I have read and agree to abide by the Substance Abuse Policy as outlined in the MSAS handbook.

I want to get to know Jesus better and follow him and live a Christian lifestyle.

I recognize that it is a privilege to be a student at MSAS because of the high standards and Christian environment. I pledge my support of these standards and will try to make MSAS a better school.

I will not act in a way that would hurt anyone physically, emotionally or spiritually. This includes my agreement to use Christian language and to avoid cursing, swearing, vulgar talk, put-downs, and threats.

I understand that even though I may not always agree with my teacher or principal, I will still support their decisions and be respectful.

Student Signature

Parent/Guardian Signature

Date

Milton-Stateline Adventist School

KIDS GROWING WITH JESUS