APPLICATION FORM

STUDENT								STUDENT SS#_____________
NAME_____________________________________________________MALE____FEMALE____
ADDRESS___________________________________________ZIP________PHONE__________
ENTERING________GRADE IN_________________, 19_______.  BIRTHDATE_______________
					(month)	          (year)					

PARENT MARITAL STATUS:         MARRIED_________DIVORCED_________WIDOWED_______
FATHER'S NAME____________________________________________SS#_________________
ADDRESS (if different from above)___________________________________________________
PHONE________________________________________________________________________
MOTHER'S NAME____________________________________________SS#_________________
ADDRESS (if different from above)___________________________________________________
PHONE________________________________________________________________________
	*In above responses, please note if guardian or step-parent
FATHER'S OCCUPATION_______________________________BUS. PHONE________________
COMPANY NAME & ADDRESS_____________________________________________________
MOTHER'S OCCUPATION_______________________________BUS. PHONE_______________
COMPANY NAME & ADDRESS_____________________________________________________
RELIGIOUS PREFERENCE__________________________________________________________
BROTHERS AND SISTERS:
	NAME		AGE	GRADE	SCHOOL
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


MATERNAL GRANDPARENTS NAME________________________________________________
ADDRESS_______________________________________CITY & ZIP______________________
PATERNAL GRANDPARENTS NAME________________________________________________
ADDRESS_______________________________________CITY & ZIP______________________
REFERENCES:
LAST SCHOOL ATTENDED_____________________________PRINCIPAL__________________
ADDRESS___________________________________________CITY & ZIP__________________
TEACHERS:  (INCLUDE TEACHERS OF MATH AND ENGLISH)
1.	NAME_____________________________________SUBJECT_______________________
	HOME ADDRESS____________________________HOME PHONE__________________
2. 	NAME_____________________________________SUBJECT_______________________
	HOME ADDRESS____________________________HOME PHONE__________________
3. 	NAME_____________________________________SUBJECT_______________________
	HOME ADDRESS____________________________HOME PHONE__________________

PLEASE ENCLOSE WITH YOUR APPLICATION:
______1)	$25.00 APPLICATION FEE (NON-REFUNDABLE)
______2)	A RECENT PHOTOGRAPH OF THE STUDENT
______3)	COPIES OF THE LAST TWO REPORT CARDS
______4)	SCORES FROM RECENT ACHIEVEMENT TESTS

I GRANT PERMISSION FOR RELEASE OF PERTINENT INFORMATION REGARDING MY CHILD TO KIRBY HALL SCHOOL.


___________________			__________________________________________
	Date								Signature