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Student Application

page-title-Student-Application

Student Information

Name *

First

Middle Name

Middle

Last Name *

Last

Home Address *

City

State

State/Province

Postal Code *

Country *

Home Phone *

Cell Phone

Email Address *

Country of Birth *

City of Birth *

State/Province of Birth

Date of Birth *

Citizenship

SSN#

Gender *

Male

Female

Residence *

HHA Dormitory

Village Student

Undecided

Which School did you last attend?

Phone

Contact Person

Reason for leaving

Highest Grade Completed

Grade 9

Grade 10

Grade 11

Grade 12

Not sure of grade

Nationality

African American

Asian

Caucasian

Hispanic

Native American

Religion

Baptized SDA

Non-baptized SDA

I attend church

Regularly

Seldom

Never

Home Church

Church Phone

Family Information

With whom are you living?

Father

Mother

Both

Other

Who is responsible for expenses?

Father

Mother

Both

Other

Name of Parents

Father

Name of Mother

Mother

Name of Guardian

Guardian

Email

Father

Mother's Email

Mother

Guardian's Email

Guardian

Father's Place of Employment

Father's Work Phone

Mother's Place of Employment

Mother's Work Phone

School Related

1. Have you ever been suspended from school for any length of time?

Yes

No

Please describe reason for suspension

Include the name of the school, length of time and when it occurred.

2. Have you ever been dismissed from a school?

Yes

No

Please describe reason for dismissal

Include the name of the school and when it occurred.

3. Do you have physical illness or handicap(s) that will limit your participation in academic, vocation, or work activities?

Yes

No

Please describe health condition

4. Have you ever been enrolled in Special Education, or Resource classes?

Yes

No

5. Please select all the apply

U.S. Citizen

Foreign student

No Visa

6. Do you play an instrument?

Yes

No

Which instrument(s)

7. When would you like to begin school?

Summer

Fall

Second Semester

As soon as possible

8. Check the types of vocation you prefer:

Radio Broadcasting

Medical Missionary

Woodworking

Food Service

Digital Photography

Auto Mechanics

Building Trade

STUDENT:
If I am accepted at Harbert Hills Academy I pledge to respect authority, and abide by the principles, and values that govern the school.

PARENT/GUARDIAN:
I/we are the legal guardians of the applicant listed above. We entrust our child to Harbert Hills Academy as testified by the act of having him/her enrolled in school. We give Harbert Hills Academy permission to act as “substitute” parents (Loco Parentis) while our child in their care. We understand that our child will participate on both the Academic, and Vocational work-study programs, and other school related activities.

Father's Signature *

Draw it
Type It
Clear

Date

Mother's Signature *

Draw It
Type It
Clear

Date

Guardian's Signature *

Draw It
Type It
Clear

Date

Sending

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