Student Name

Prefix
Firstrequired
Middle
Lastrequired
Suffix

Applying for graderequired

For School Yearrequired

Current Graderequired

PRE-KINDERGARTEN

PreK 2 year olds

T, TH Half Days

PreK 3 year olds

5 Half Days 5 Full Days

PreK 4 year olds

5 Half Days 5 Full Days

Proof of age (a birth certificate) must be submitted at the time of registration. An up-to-date immunization record certified by a doctor must also accompany the application. Three-year-olds must be three by December 1st and independent in the bathroom. Four-year-olds must be four by December 1st.

STUDENT INFORMATION

Prefers to be called

Genderrequired

Date of Birthrequired (mm/dd/yyyy)

Birthplace

Citizenship

Language spoken at home

Home Address

Address 1required
Address 2
Address 3
Cityrequired
Staterequired
Region
Zip Coderequired (ex. 06108 or 06108-0809)
Country

Home Phonerequired

Public school district in which student resides:

Has your child previously attended school?*

yes no

Previous schools and years attended:

Does your child currently attend school?*

yes no

Current School

Current School Address

Address 1
Address 2
Address 3
City
State
Region
Zip Code (ex. 06108 or 06108-0809)
Country

Current School Phone Number:

Has your child ever been withdrawn from a school, suspended, expelled, or placed on probation?

Yes No

Please explain.

FAMILY INFORMATION

Parent/Guardian 1 Information:

Prefix
Firstrequired
Middle
Lastrequired
Suffix

If guardian, state relationship:

Is Parent/Guardian 1 address different from home address?*

yes no

Parent/Guardian 1 Address:

Address 1
Address 2
Address 3
City
State
Region
Zip Code (ex. 06108 or 06108-0809)
Country

Parent/Guardian 1 Home Phone:

Parent/Guardian 1 Cell phone

Parent/Guardian 1 Email:

Parent/Guardian 1 Employer:

Parent/Guardian 1 Occupation:

Parent/Guardian 2 Information:

Prefix
First
Middle
Last
Suffix

If guardian, state relationship:

Is Parent/Guardian 2 address different from home address?

yes no

Parent/Guardian 2 Home Address:

Address 1
Address 2
Address 3
City
State
Region
Zip Code (ex. 06108 or 06108-0809)
Country

Parent/Guardian 2 Home Phone:

Parent/Guardian 2 Cell Phone

Parent/Guardian 2 Email Address

Parent/Guardian 2 Employer:

Parent/Guardian 2 Occupation:

Applicant lives with

Do you have any relatives or friends who attend/attended HCDS?*

yes no

Could you please provide the Name, Years Attended and Relationship of each person:

How did you hear about us?

PARENTS' COMMENTS

What are your educational goals for your child and how do you see HCDS as a contributor in reaching those goals?

Are there any experiences that have influenced your child of which we should be aware?

Do you have any additional thoughts or comments you wish to submit?*

yes no

Additional thoughts or comments:

Please submit your application below, and a representative of our admission department will contact you shortly. Thank you for your interest in Harbor Country Day School.