Top Private School San Diego,Private School in San Diego - Domestic Form

STUDENT INFORMATION

School year applying for:

First Name:

Last Name:

Middle Name:

DOB:

Place of Birth:

Gender: FM

Current Grade Level:

Grade Level your child will be in next school year:

Mother’s Name:

Home Phone:

Address:

Work Phone:

City:

State:

Zip:

Cell Phone:

Email address:

Father’s Name:

Home Phone:

Address:

Work Phone:

City:

State:

Zip:

Cell Phone:

Email address:

Please notify the office immediately if any of your contact information changes.

Stepfather’s Name:

Work Phone:

Email address:

Cell Phone:

Stepmother’s Name:

Work Phone:

Email address:

Cell Phone:

For school profile only.

Student’s ethnicity:

Student’s primary language:

Highest level of education for dad:

Highest level of education for mom:

MEDICAL INFORMATION

My child is currently being treated for the following medical conditions:

My child has allergies?

Please list:

Medications	For what conditions?	Dosage	Frequency	Date Started

My child takes medications during the school day:

Please list:

Are there other major conditions in your family?

PERMISSION AND EMERGENCY INFORMATION

Besides parents/guardians, the following individuals have permission to pick up my child and may be notified in case of an emergency:

Name:

Relationship:

Phone:

Name:

Relationship:

Phone:

Name:

Relationship:

Phone:

In case of an emergency, I give permission for Balboa School to seek, authorize, and consent to any medical treatment or care necessary for my child. This authorization, hereby granted to Balboa School, shall continue in effect until such time as I make direct contact with the treating doctor. This authorization in no way obliges Balboa School or its authorized representatives, to pay or be liable for any costs or expenses incurred in the care of or treatment of my child; and I agree to pay all costs and expenses incurred for the treatment and case of my child.

Parent/Guardian Name (please print):

Parent/Guardian Signature:

Date:

ADDITIONAL CONTACTS

My child is known to the following professionals (physician, psychologist, psychiatrist, social worker):

Name:

Title:

Phone:

Email:

Name:

Title:

Phone:

Email:

SCHOOL INFORMATION

Previous School & year(s) attended:

School:

Grade & Year attended:

School:

Grade & Year attended:

Current GPA:

After high school my child is interested in: 4 year University Community College Vocational School Working

The major my child is interested in is:

PROGRAM PARTICIPATION

Throughout the course of the year, students at Balboa School take a variety of field trips. These trips range from visiting museums to
touring college campuses. We consider it an integral part of our program that students become exposed and interact within the
community around them. Students will either walk, take a taxi, or ride with parent volunteers. I understand my child will go on off
campus field trips with Balboa School. I understand that the staff of Balboa School will take reasonable care of my child, but I also
recognize that they will be off campus and may occasionally encounter hazards beyond the staff’s control. I agree to be fully responsible
and hold harmless Balboa School, and any of its employees and parents, from any and all liability for any and all harm arising to my child
as a result of participating. This will hold true for any and all years that my child attends Balboa School.

Balboa School maintains the right to all student-generated work produced, created, or developed at Balboa School by my child. It also
maintains the right to use my child’s image in stills, video tape recordings or other media, such as the internet and/or yearbook, in such a
way as it deems fit for now or in the future for publicity or other purposes. My child’s name may be used in conjunction with Balboa
School events, publicity and other ways as it deems fit now or in the future for publicity or other purposes. Balboa School has my
permission to use photos and student-generated work.

In addition, consequent to any tuition payment made to Balboa School, I understand and agree I will not receive a refund.

My signature below indicates that I have read and agree to the above and that all information on this application is complete and factually
presented.

Parent/Guardian Name (please print):

Parent/Guardian Signature:

Date:

Domestic Application Form

STUDENT INFORMATION

MEDICAL INFORMATION

PERMISSION AND EMERGENCY INFORMATION

ADDITIONAL CONTACTS

SCHOOL INFORMATION

PROGRAM PARTICIPATION

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