Shiloh SDA Church School

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School Year: 2015-2016
Complete Part I and Part II on application for each child applying for admission. Fill out Part III for one child per family only. Answer every question. Place N/A where applicable. 
Part I
Child’s History
Name of Child: __________________________________________________________
      Last                                  First                         Middle Name (not initials)
Address: ______________________________    Date of Birth _____________
                ______________________________   Place of Birth _____________
                ______________________________ Gender:  Male          Female 
     S.S.N. ________________________
Home (     ) ______________ Work (       )______________ Cell (    )__________
Member of what church __________________________________________
Grade Level Completed _________
Last School Attended ______________________________________________________
Address where records can be obtained _______________________________________
Part II
 Medical History
Emergency Contact Person _________________ Relationship to child ___________
Telephone (      )  _____________
Family Physician: _____________________ Telephone (     )___________________
List all allergies ____________________________________________________________________
Give any medical conditions ____________________________________________________________________
Part III 
Family Data
 (Complete one for each family. Only provide the Social Security Number for the
person signing.)
Father’s Name____________________   Mother’s Name___________________
Guardian’s Name________________________________________
SSN ______________________
Email Address ______________________________________________________
Father _______________________    Mother ________________________
Guardian _____________________
Educational Status
Father __________________           Mother _________________________
Guardian ______________________
Parental Agreement
I, (please print) ________________________ have read and understood the policies
governing the Shiloh SDA Church School, and I promise to abide by them. I will do all in my power to see that my child is present and on time every day. I will endeavor to
cooperate with the school board and teachers by avoiding adverse discussion of any
teacher or school policies in the presence of the student. I agree to give my financial
support by promptly paying the registration fee and the monthly tuition. 
_________________________________________         _________________
  Signature of Parent/Guardian                                                        Date