Admission Application

mm dd yyyy

Student's Full Name: " "

first middle last nickname

Date of Birth: / / Social Security Number: – –

mm dd yyyy

Parent/Guardian Full Name:
Home Address:

street apt. # city state zip

Home phone: – – Business phone: – –
Employer/Occupation:
Business Address:

street apt. # city state zip

Other Parent/Grandparent/Guardian to whom billing, report cards, school information, etc. should be sent (Circle any applicable)

Name: Relationship to Student:
Home Address:

street apt. # city state zip

Home phone: – – Business phone: – –
Employer/Occupation:
Business Address:

street apt. # city state zip

Two persons other than parents to contact in case of emergency

Name: Phone: – –
Relationship:

How did you become interested in Gateway School?

Additional information

Health and Fitness

Applicant’s physician: Telephone: – –

Address:

Health Insurance Co.: Policy #:

Applicant’s physical restrictions/allergies/medications:

Please attach to this form documentation copies (for our files) of any updated immunizations, vision, hearing, scoliosis, or other physical/health examination results.

Activity Permission and Release Agreement

I hereby certify that my son/daughter has my permission to participate in field grips and activities as authorized by Gateway School.

To the best of my knowledge, he/she is physically fit to engage in such activity and is not suffering from any disease or injury.

I hereby waive and release all claims against Gateway School and any employee or representative of said school, and agree to indemnify such parties and hold them harmless from any claim for any injury or sickness, or any loss or damage to property, that may be suffered by or occur to my son/daughter, or any claim resulting from any action of my son/daughter.

If, in the judgment of any school representative, my son/daughter should need immediate care and treatment as a result of any injury of sickness, I do hereby request, authorize and consent to such care and treatment at my expense as may be given and do hereby agree to indemnify and save harmless the school and any school representative from the claim of any person whomsoever on account of such care and treatment of my son/daughter.

Date ___________ __________________________ __________________________

mm/dd/yyyy Parent/guardian signature Student signature (if 18 or over)

Application for Admission

Health and Fitness

Activity Permission and Release Agreement