Spencerville Advenist Academy Application Form

Spencerville Adventist Academy

15930 Good Hope Road, Silver Spring, MD 20905

Phone: 301-421-9101 Fax: 301-421-0007

APPLICATION FORM

(Attach Photo)

Applicant’s Name________________________________________________________________________________

(Last) (First) (Middle)

Grade applying for________ Race___________ Gender_____ Age_____..Date of Birth ___ /___/ _____mm/dd/yryr

Applicant’s Address_______________________________________________________________________________

Home Phone____________________Cell Phone/Beeper__________________Place Birth_______________________

Student’s Church Membership_________________________________________Date of Baptism_________________

(Denomination/Location)

Billing Address if different from above__________________________________________________________________

Father’s Name________________________________ Mother’s Name___________________________________

Social Security #________________________ Social Security # _______________________

Address (if different)_________________________ Address (if different)____________________________

__________________________________________ _____________________________________________

Occupation_________________________________ Occupation ___________________________________

Business Phone_____________________________ Business Phone________________________________

U.S. Citizen _________ y/n U.S. Citizen_________ y/n

Church Membership__________________________ Church Membership_____________________________

(Denomination) (Denomination)

____________________________________________ _____________________________________________

(Location) (Location)

Home Status: Married________ Separated________Divorced________Remarried_______Widowed_________

Name of Custodial Parent/Legal Guardian_________________________________________________________

Name and Address of School last attended:_________________________________________________________

Children in family in order of birth including student:

Name_____________________________________Sex_______Birthdate_________________________________

PERSONS TO NOTIFY IN CASE OF EMERGENCY:

___________________________________________________ Phone__________________________

Family Physician________________________________ Phone__________________________

Date of Last Physical Examination________________________________________________

Has the student ever been dismissed from any school because of unsatisfactory scholarship conduct?

Yes_____ No_____ If so, where and why?_______________________________________________________

____________________________________________________________________________________________

Has the student ever or within the last six months used: Drugs? Yes______ No_______

Liquor? Yes______ No______ Tobacco? Yes ______ No________

Has the student attended Spencerville Adventist Academy Previously? If So, what Year_______________

Does the student have credit for or is he/she now taking correspondence work? Yes_____ No_______

If so, what course?_____________________ Where?______________________

Is there any physical or health condition which would hinder him or her In carrying a full

school program? Yes_______No______ If so, describe__________________________________________

Do you owe an account at any other school?_____If so, where?__________________________________

REFERENCES

1. Pastor___________________________________________________Phone_______________________

2. Teacher/Principal__________________________________________Phone_______________________

3. Other____________________________________________________Phone_______________________

STUDENT PLEDGE: I am in full harmony with the principles of Spencerville Adventist Academy. If accepted,
I hereby agree to obey the regulations and to cooperate in upholding the standards of the school.

Signed__________________________________________________________Date_____________________

CONTRACT OF PARENT OR GUARDIAN: I am in full harmony with the principles of Spencerville Adventist Academy
as stated in the handbook, or as shall be announced by the Principal and the School Board during the year,
and I agree to assume full financial responsibility for the student.

Signed __________________________________________________________Date______________________

Please submit with $35.00 application fee.

DO NOT WRITE BELOW THIS LINE

Application Date__________Fee_______Transcript_______Immunization Record_________

Admission Committee Action: Accepted_______ Waiting List_______ Rejected_________

Other Comments_______________________________________________________________