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:

Milton-Stateline Adventist School

KIDS GROWING WITH JESUS