Student Registration

Student Application (one per student)

Applicant's Name

Birthdate

Current School

Current Grade

Applying for School Year

Applying for Grade

Describe the Applicant's Education History (previous school, classes, curriculum used)

Describe the Applicant's Extracurricular Interests and/or Achievements

Has the Applicant been tutored?

Yes No

Has the Applicant been subject to disciplinary action?

Yes No

Has the Applicant skipped or repeated a grade?

Yes No

Has the Applicant had any learning or behavioral problems?

Yes No

Does the Applicant have any physical disabilities or illnesses?

Yes No

Are you aware of any issues that may affect the Applicant's behavior or academics?

Yes No

If yes to any of these questions, please provide a complete explanation.

Recent Photo of Applicant

Recent Report Card of Applicant

We certify that all of the information on this application is true and complete, and we authorize Imago Dei Academy to contact the Applicant's previous school(s) and teachers to obtain records and opinions regarding the Applicant.

Father's Typed Signature

Date

Mother's Typed Signature

Date

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First Name

Last Name

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