Student Application.pdf - Google Drive

Office Use

Please mail application to:

Year applying for: _____________________

Karen Rowley 14631 NW Ash St. Portland 97231 Phone: 503-504-3652

Date submitted: ______________________ Application fee received: Cash Check # ____

Application for Admission Families and students of all religious affiliations, faiths, and races are welcome at Pioneer Heritage Academy. Upon receipt your application will be reviewed and your student will be placed on a waiting list. When space becomes available, you will be notified and we will schedule a student/parent interview with the administrator and another board member. If your child is accepted, the $25.00 application fee will be applied to the $25.00 registration fee. If your child is not accepted, the application fee will be refunded.

Student Information Name: ____________________________________________________________________________________________________ Date of Birth: _______________ Gender: ______ Current Age: _________ Current Grade: _______________ Applying for Grade: ______________ Applying as a:

Full-time student

Part-time student

Father’s Name: _____________________________ Mother's Name: _________________________________ Address: __________________________________________________________________________________ Father’s Phone: ____________________________ Mother’s Phone: _________________________________ Home Phone: ______________________________ Preferred Contact Phone: __________________________ Parent E-mail: ______________________________ Student E-mail: __________________________________

Student’s Educational Information Student is currently attending:

Public school

Private school

Home school

Name of current school: ___________________________________________ Phone: ____________________ Address: __________________________________________________________________________________ Has student ever skipped or repeated a grade? Has student ever been expelled? Student is changing schools:

Yes Voluntarily

No

Yes

No

If yes, please explain below

If yes, please explain below Involuntarily

If involuntarily, please explain below

Explanations: _______________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________

Student Please explain in your own words why you want to attend Pioneer Heritage Academy. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________

Parents Please explain why you want your child to attend Pioneer Heritage Academy. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________

Family Commitment In signing this application, we attest that: 1. We have answered the questions in this application completely and honestly to the best of our knowledge and ability. 2. We have read the Mission, Governing Principles, and Policies of Pioneer Heritage Academy. (Please refer to www.pioneerheritageacademy.org.) 3. We will provide sufficient time and effort to fulfill the parental requirements and responsibilities of each course our child takes, and we will attend/participate in any mandatory meetings.

Signature of Student

Printed Name

Date

Signature of Father/Guardian

Printed Name

Date

Signature of Mother/Guardian

Printed Name

Date