App Testing

Seneca Academy Online Application
Applying Student Name*		?
Today’s Date*
Application for Grade*	-None- Kindergarten Grade 1 Grade 2 Grade 3 Grad3 4 Grade 5
Entering Fall of Year*
Preferred Email Contact*
Student Last Name*
Student First Name*
Student Middle Name
Prefers to Be Called*
Date of Birth*
Gender*	-None- Female Male
Address Line 1*
Address Line 2
City*
State*	-None- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming
ZIP Code*
Home Phone
Custodial Parent/Guardian 1 Title	-None- Mr. Ms. Mrs. Dr. Other
Custodial Parent/Guardian 1 Last Name*
Custodial Parent/Guardian 1 First Name*
Relation to Child*
Email*
Email Parent 1
Cell*
Call Parent 1
Home Address (If Different)
Occupation*
Employer*
Custodial Parent/Guardian 2 Title	-None- Mr. Ms. Mrs. Dr. Other
Custodial Parent/Guardian 2 Last Name
Custodial Parent/Guardian 2 FIrst Name
Relation to Child
Parent 2 Email
Email Parent 2
Parent 2 Cell
Call Parent 2
Parent 2 Home Address (If Different)
Parent 2 Occupation
Parent 2 Employer
Noncustodial Parent Title	-None- Mr. Ms. Mrs. Dr. Other
Noncustodial Parent Last Name
Noncustodial Parent First Name
Noncustodial Parent Relation to Child
Noncustodial Parent Email
Noncustodial Parent Cell
Noncustodial Parent Home Phone
Noncustodial Parent Home Address
Sibling 1 Name
Sibling 1 Gender	-None- Female Male
Sibling 1 DOB
Sibling 1 Current School
Sibling 1 Grade
Sibling 2 Name
Sibling 2 Gender	-None- Female Male
Sibling 2 DOB
Sibling 2 Current School
Sibling 2 Grade
Sibling 3 Name
Sibling 3 Gender	-None- Female Male
Sibling 3 DOB
Sibling 3 Current School
Sibling 3 Grade
Sibling 4 Name
Sibling 4 Gender	-None- Female Male
Sibling 4 DOB
Sibling 4 Current School
Sibling 4 Grade
Returning Seneca Academy Family*	-None- Yes No
How did you hear about us?*
Current/Former Families Known
Current School and Address
Previously Attended Schools
Strengths
Growth Edges
Interests/Hobbies
Peer Relationships
Goals
Miscellany
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