Student Application
Date _____________
Name: _________________________________________________________________
(Last) (First) (MI)
Address ________________________________________________________________
City: ____________________________________ State: ______________ Zip: _______
Telephone: ________________________ Birthdate: __________________ Age: ______
Male/Female (circle one) Social Security Number: ___________________________
Last school attended: ________________________________ Last grade completed ____
Address: ________________________________________________________________
Under what condition did the student leave the previous school? ____________________
________________________________________________________________________
How was the student’s work while in school? Did the student receive any special services or help? __________________________________________________________
________________________________________________________________________
Family Information
Parents (legal guardian) Name: ______________________________________________
Employer’s name, address and phone: _________________________________________
________________________________________________________________________
How did you hear about the school/referred by whom? ___________________________
Student’s Medical Information
Does the student have any physical problems or allergies? Yes/No Explain: __________
________________________________________________________________________
Is the student on any prescription medication? Yes/No Type: ______________________
Physician’s Name: _______________________________ Phone: __________________
When the parent (legal guardian cannot be reached in an emergency, who should be called? (circle one) neighbor relative friend
Name: _______________________________________ Phone _____________________
Name: _______________________________________ Phone _____________________
Hospital preference in case of emergency: _____________________________________
Permission to transport student via EMSA in case of emergency: ____Yes ____ No
Who has automatic permission (not written) to pick the student up from school other tan the parent (legal guardian)?
Name: ____________________________________________
Student Signature: __________________________________________
Parent (legal guardian Signature: _______________________________________
Destiny Urban Academy admits students of nay race, color, national or ethnic origin, and religious faith. Destiny Urban Academy does not discriminate on the basis of race, color, national or ethnic origin or religious faith. All privileges, programs, and activities are made available to the students at this school are the same, as well as the administration of its education policies and other school administrative programs.
________________________________________Office Use Only____________________________________________________________
Date accepted: __________ Parent (legal guardian) informed: _____________________
Tuition per semester: ______________
Date rejected: _________________ Parent (legal guardian) informed: _______________
Findings: _______________________________________________________________