Application Follow the steps below to begin the registration process for Middlebrooks Academy: 1. Enter the the student’s name and then click the “Buy Now” button and follow the necessary steps to securely pay for your application through PayPal. All major credit cards are accepted. Input Student’s Name *NOTE: PAYMENT OF APPLICATION FEE IS NON-REFUNDABLE 2. Completely fill out the application form below and click submit. If you are a human and are seeing this field, please leave it blank. Fields marked with a * are required. Student Applicant Name * Home Address * Home Phone * Place of Birth * Apply For What Grade * 9th Grade 10th Grade 11th Grade 12th Grade Citizenship (USA or Other - please specify) * If not US citizen, type of Visa or classification Social Security Number Father Name * Home Address * Cell Phone * Occupation & Employer * Business Address * Work Phone * Are you the biological father? (Yes or No) * Yes No If not, are you the stepfather or guardian? Mother Name * Address (Street, City, State, Zip Code) * Cell Phone * Occupation & Employer * Business Address * Work Phone * Are you the biological mother? (Yes or No) * Yes No If not, are you the stepmother or guardian? Student Applicant Lives With * Both Parents Mother Father Legal Guadian In cases of divorce or separate households, correspondence from the school should be sent to who? Who will assume full financial responsibility? * Social Security Number Address * Cell Phone * In case of emergency, please provide a non-parental contact name and phone number. Emergency Contact Name * Emergency Contact Phone Number * Current School of Applicant * School Address * School Phone * Previous School of Applicant * School Address * School Phone * Previous School of Applicant School Address School Phone Previous School of Applicant School Address School Phone How did you learn about our school? * Parental Statement Of Recommendation * What academic preparation are you expecting from our school? * What co-curricula activites are you expecting from our school? * Please explain any academic or personal issues that we should consider for acceptance to our school. All the information supplied on this application is true and correct to the best of our knowledge * All information gathered confidentially with reference to the applicant will be used solely by the Admissions Director or their delegates. By signing this application: (1) I authorize my child's previous schools to release the applicant's academic records and test scores for the purpose of evaluating the application for admission; (2) I authorize administrators, teachers and counselors to complete confidential recommendation forms; (3) I waive any rights I my otherwise have to access the evaluation materials and the confidential recommendation forms before or after the admission decision is made; (4) I fully understand that as a parent I have rights under Education Code section 49069 to access any and all pupil records of my child once they are admitted to Middlebrooks Academy. I understand my rights under Education Code section 49069 and hereby knowingly and willingly waive all rights under section 49069 to access the evaluation materials and confidential recommendation forms submitted in reference to my child's application and (5) I hereby release every person and institution from any and all liability including liability for defamation and/or invasion of privacy, resulting from or pertaining to information received regarding this application. Furthermore, I am waiving any rights I may otherwise have with regard to this information. * 3. To complete your appplication, please email a copy of your transcripts and standardized test scores to email@example.com.