THOMAS HEYWARD ACADEMY
Application for Admission
Complete and return pages 2
through 4 of the Application for Admission to:
20____ 20____ School year Entering
Grade _______
Please Print Clearly:
Student’s Name
______________________________________________________________________ Male ____
Female____
Last
First Middle
Name or nickname by which student is called: ___________________________ Social Security #: ______________________
Address
_______________________________________________________________ Phone
#: _______________________
City
___________________________________________________ State
_____________ Zip
_________________________
Date of Birth
______________________ City
& State of Birth ________________________
Country _____________________
Ethnicity
_________________________
Religion
________________________ Church ______________________________
Father’s Name
_____________________________________________ Cell Phone #
_________________________________
Address (if different)
___________________________________________________ City
_____________________________
State ___________
Zip Code ____________ Employer
_______________________ Phone
#: _________________________
Mother’s Name
_____________________________________________ Cell Phone #
_________________________________
Address (if different)
___________________________________________________ City
_____________________________
State ___________
Zip Code ____________ Employer
_______________________ Phone
#: _________________________
Marital Status:
Married ____ Separated ____ Divorced
____ Widowed ____
Remarried ____
Is there a court order of any type in existence, which
precludes or restricts either parent, or any relative, from having contact with
your child? Yes ____ No ____
If the answer is YES, please attach a copy of the court order to
this application.
Emergency #’s and Contacts:
_______________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
If the student is not living
with his or her mother or father, complete the following:
Address:
___________________________________________ City __________________________
State______ Zip _______
Phone #:
______________________ Work
Phone #: ________________________ Cell Phone #: ______________________
List other
children/step-children, their ages and the school they attend:
(Please list other
children/step-children on the back of this page.)
Name
_____________________________________________ Age ________ School
_________________________________
Name
_____________________________________________ Age ________ School
_________________________________
Please
Initial: ____________________
Student’s Name (Last, First,
MI)
____________________________________ Entering Grade ______
20____ 20____ School Year
City
________________________________________________________ State ________________
Zip Code _____________
Phone # ___________________________________________ Fax #
______________________________________________
What are your child’s academic strengths?
____________________________________________________________________
______________________________________________________________________________________________________
In what areas does your child need to improve
academically?
_____________________________________________________
______________________________________________________________________________________________________
What are the primary reasons that you desire for your child
to attend Thomas Heyward Academy?
________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Has your child ever been recommended for testing, been
tested and/or diagnosed for any of the following conditions? Check all that apply. If any are checked, please explain below,
giving specific information.
_____
Academically Gifted _____ Hyperactivity _____ Orthopedic
Impairment
_____
Attention Deficit Disorder _____
Learning Disability _____
Speech or Language Impairment
_____
Emotional Disability _____
Mental Retardation _____Visual
Impairment
_____
Hearing Impairment _____
Neurological Impairment _____
Other: _____________________
Explanation:
____________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Has your child ever received special academic help (such as
tutoring/resource/or remedial) or a modified curriculum? If so, please describe:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Has your child ever been expelled or suspended from school
or had any criminal charges filed against them? If so, please describe:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Reg.: ________ Testing:
________ B. Fund: _________ Books
________ Locker: ________ Lab Fees: ________ Supply
Fees: ________ Date Enrolled: _______________ T&A: ______________ Building Fund Paid:
__________
______________________________________________
Signature
of Parent or Guardian