Student Application

Step 1 of 5

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Date

MM slash DD slash YYYY

Last Name:(Required)

Student’s given name

First Name:(Required)

Student’s first name

Middle Initial:(Required)

Student’s middle initial

Goes By(Required)

Student’s nickname

Grade to Enter

Age

Please enter a number from 3 to 18.

Birth Date

Month

Day

Year

Gender

Male

Female

Home Phone

Student Email

Mailing Address

Street Address City State / Province / Region ZIP / Postal Code Country

Is Mailing Address Same as Home Address?

Yes

Residential Address

Street Address City State / Province / Region ZIP / Postal Code Country

US Citizen

Yes

Permanent Resident

Yes

Type of Visa

Visa Expiration Date

MM slash DD slash YYYY

Has your child ever been under the care of the following?

Choose all that apply

Babysitter

Preschool

Sunday School

Daycare

Does the applicant separate easily from the parent/legal guardian?

Yes

Can the applicant be understood by the teacher at the single word level?

Yes

Can the applicant be understood by the teacher in connected speech?

Yes

When spoken to, does the applicant listen and respond?

Usually

Sometimes

Rarely

When asked to do something new, is the applicant willing to try?

Yes

Can the applicant stay focused on an individual project/activity?

Yes

Is the applicant potty trained?

Yes

Does the applicant have frequent potty training accidents?

Yes

Previous School

Has your child attended HCA in the past?

Yes

Grade Level(s) Attended (Choose all that apply)

Pre-K

Has your child ever been dismissed from another school?

Yes

Please Explain:

Does your child have any physical, emotional, or academic disability?

Yes

Please Explain:

Does your child have or need an IEP/ISP (Individualized Education/Service Plan)?

Yes

Please Explain:

Has your child ever been retained and not promoted to the next grade level?

Yes

What Grade(s)? Choose all that apply

Pre-K

Church Your Family Attends (if applicable)

Father

Last Name

First Name

Employer

Position

Cell Phone

Work Phone

Marital Status

Single

Married

Seperated

Divorced

Widowed

Mother

Last Name

First Name

Employer

Position

Cell Phone

Work Phone

Marital Status

Single

Married

Seperated

Divorced

Widowed

Other (If Applicable)

Legal Status

Power of Attorney

Legal Guardian

Last Name

First Name

Employer

Position

Cell Phone

Work Phone

Marital Status

Single

Married

Seperated

Divorced

Widowed

Have legal documents been provided?

Yes

List of provided legal documents

Other Children in the Family

Name

Sex

Age

Grade

Name of School Attending

How did you hear about HCA?

Website/Web Search

Open House

Newspaper

Current Family

Referred By

Name

Date Available for Interview

Please bring the following: 1. Birth certificate 2. Current report card 3. Final report card (previous school year if applicable) 4. High school report cards or transcript (if applicable) 5. Most current SAT (if applicable) 6. Current immunization record (including PPD test within 6 months of student’s arrival on Guam) 7. Original notarized guardian letter (if applicable)

MM slash DD slash YYYY

Would you also like to schedule a campus tour at the interview time?

Yes

Harvest Christian Academy admits students of any race, color, national and ethnic origin to all the rights, privileges, programs, and activities generally accorded or made available to students at the school. It does not discriminate on the basis of race, color, national and ethnic origin in administration of its educational policies, admissions policies, scholarships, and athletic and other school-administered programs.(Required)

I have read and acknowleged HCA’s non-discrimination policy

Last Name(Required)

Person filling out application

First Name(Required)

Person filling out application

Email(Required)

Person filling out application