Please fill out the following form.  An * indicates an optional field.

Section A Student Name

Last name:  First Name:  Middle name:

Social Security Number:

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Section B – Student Information

Name that student will use at school:

Sex: Male Female    Age:  Birthday (Month/Day/Year):

Place of birth: (city/state or county):

Student resides at Address:  City:  State:  ZIP:

Home phone number:  Alternate:*

* Medical needs and special conditions: (Include explanation of any medical conditions/allergies affecting your child that the school should be aware of)

* Custody comments: (If any)

* Special religious needs or observances: (If any)

Seventh-day Adventist Members Only:

*Baptized: No Yes   *Church membership:

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Section C – Grade for which Student is Applying (Final placement will be determined by Foothill SDA School.)

Grade: All day Kindergarten (8:00AM-3:00PM) 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade

Note: Kindergarten entrance age--Must be 5 by December 2

Daycare is available before and after school. 

My child be enrolled in Daycare: No Yes  

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Section D – Consent to Treatment

I hereby authorize the Foothill SDA Elementary School Staff to call an emergency ambulance in case of accident or acute illness, and to arrange for necessary emergency and surgical care, in case I am not immediately available.  Any qualified physician, or dentist, called by Foothill, may treat and do whatever is necessary for the well being of my child.  It is understood that every effort will be made to notify me before the above action is taken.  I also agree to accept responsibility for the cost of the above medical or dental treatment.

Physician’s Name:  Physician’s Phone #:

Hospital  Preference:

I authorize treatment as stated in Section D: No Yes

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Section E – Parent/Guardian Acknowledgement

I understand that the annual tuition has been divided into ten (10) equal payments, that the first payment is due in August, that a full monthly payment is due in December, that the REGISTRATION FEE OF $200 is non-refundable, and that the pre-paid current month’s tuition will be pro-rated and REFUNDED provided FOOTHILL S.D.A. ELEMENTARY IS NOTIFIED IN WRITING THIRTY (30) DAYS PRIOR TO WITHDRAWING MY CHILD.

I have provided written notification above of any medical conditions/allergies or physical conditions that affect my child. I have read, understand, and agree to abide by the policies as outlined on the following pages of this form.

I/We agree to pay all attorney fees, court costs, filing fees, including charges or commissions up to 50 percent of principal balance that may be assessed to Foothill School by any collection agency retained to pursue past due balances.  I/We further agree to pay interest at the rate of 1 ½ percent per month (18 percent per year) on such balances. 

I understand that this is only an application for admission and that is not considered accepted until I have received an enrollment acknowledgement letter signed by the principal.

I/We agree to the terms and conditions stated in Section E: No Yes

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SECTION F – Parent/Guardian Information (Please list persons responsible for student.)

Parent 1

Last Name:  First Name:  Middle Name:

Relationship: Father Mother Guardian Other  

Home Phone:  Pri work phone: *Alt work phone: 

*Cell Phone:  *Pager:  *Email:

Home Address:  City:  State: Zip:

*Occupation:  *Employer name:

Marital status: Married Seperated Divorced Other  

*SDA Member? No Yes *Church Membership at:

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Parent 2

Last Name:  First Name:  Middle Name:

Relationship: Mother Father Guardian Other  

Home Phone:  Pri work phone: *Alt work phone: 

*Cell Phone:  *Pager:  *Email:

Home Address:  City:  State: Zip:

*Occupation:  *Employer name:

Marital status: Married Seperated Divorced Other  

*SDA Member? No Yes *Church Membership at:

Person responsible for tuition payments:

Name:  Home phone: 

Street address: City:State:  Zip:

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Section G – Sibling Information

*Name of sibling1:  *Birthday:

*Name of sibling2:  *Birthday:

*Name of sibling3:  *Birthday:

*Name of sibling4:  *Birthday:

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Section H – Student Release Authorization: My children may be released to the following people:

  Name 1:   Relationship: Relative Sibling Friend     Phone:

*Name 2:  *Relationship: Relative Sibling Friend   *Phone:

*Name 3:  *Relationship: Relative Sibling Friend   *Phone:

*Name 4:  *Relationship: Relative Sibling Friend   *Phone:

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Section I – Schools Student Has Attended for Last Two Years

*Name of school 1:  *Grades Attended:

*Address:  *City:  *State:  *Zip:

*Phone Number:

*Name of school 2:  *Grades Attended:

*Address:  *City:  *State:  *Zip:

*Phone Number:

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Section J – Additional Information

I first heard about Foothill S.D.A. Elementary from: Referral Web Site Yellow Pages Other

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