High School Application

Student Applicant Name*
First Last
Student Applicant Date of Birth*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Student Email*
Home Phone*
Place of Birth*
Citizenship (USA or Other - please specify)
Social Security Number

Father Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Cell Phone*
Father Email*
Occupation & Employer*
Business Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Work Phone*
Are you the biological father? (Yes or No)*
If not, are you the stepfather or guardian?*

Mother Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Cell Phone*
Mother Email*
Occupation & Employer*
Business Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Work Phone*
Are you the biological mother? (Yes or No)*
If not, are you the stepmother or guardian?*

Student Applicant Lives With*
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*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Cell Phone*

In case of emergency, please provide a non-parental contact name and phone number.
Emergency Contact Name*
Emergency Contact Phone Number*

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.*
Consent

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.