BETHESDA S.D.A JR. ACADEMY

76 Parkway Ave
Amityville, NY, 11701
631-842-3321


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Application for PK to Grades10
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Bethesda Junior Academy
76 Parkway Ave.
Amityville, NY 11701
         Phone:: 631-845-3321 Fax: 631-845-3322

 


General Information
Grade Appling For:
*

My Child is a:
 New Student;   Returning Student;  *

 

Firstname:
*
Middlename:
*
Lastname:
*
Birthdate(MM/DD/YY):
*
Citizenship:
*
Sex:
 Male;   Female;  *
Local School District:
*
Last District & School Attended:
*
Last Grade Completed:
*

Children of the Family
Number of children in Family:
xx
Number of Boys:
Number of Girls:
Indicate the Childs Position in the Family (1 being the eldest):  1;   2;   3;   4;   5;   6;   7;   8;   9;   10; 
Home Address 1:
*
City:
*
Zip:
*
Home Address 2:
State:
*
Country:
*
Home Phone:
*
Cell Phone:
*
Work Phone:
*

Chuch Affiliation
Seventh-day Adventist Church:
 Yes;   No;  *
Baptized Member:
 Yes;   No;  *
Name of Church:
Church Address:
Church Phone:
Name of Conference:

Emergency Contact Information
Emergency Name:
Emergency Relationship:
Emergency Address:
Emergency City:
Emergency State:
Emergency Zip:
Emergency Phone 1:
Emergency Phone 2:
 
Physician/Clinic:
Physician Phone:
 Physician Address:
 Physician City:
 Physician State:
 Physician Zip:

Acadenic Status
 Were you told to attend summer school?
 Yes;   No;  *
 Do you have a copy of your Summer School Report:
 Yes;   No; 
 Were you ever suspended from your last school:
 Yes;   No;  *
Have you used any of the following recently      Tabacco:
         Liquor:
Illegal Drugs:
 Yes;   No;  *
 Yes;   No;  *
 Yes;   No;  *
 
If you answered yes to the use of Tobacco, Liquor, or Illegal Drugs, please tell us how recently and explain:
Are you alergic to any food or medication:  Yes;   No;    
Please list foods and medications that you are allergic to:
The Teacher that influenced me the most taught me to: *

Student Commitment
Do you desire to live a Christian life:
 Yes;   No;  *
I am willing to obey the rules and regulations stipulated by this institution:
 Yes;   No;  *
 Date:
*

IMPORTANT NOTICE

If at any time during the school year any of the above information changes, you are required to notify the office immediately. In the event of an emergency, it is imperative that we have the most current contact information.

Please collect Church Constituent verification Form from the school.



Submit Application
Fields marked with an * are required.