Applying for:
____One Semester ____One
Year
____Spring 2003 ____Summer
2003____Fall 2003____Winter2003
PERSONAL INFORMATION
Name of Applicant:__________________________________________
Permanent Address:_________________________________________
Telephone: _______________________
Fax: _____________________
Shirt Size: _________________Email:
___________________________
Social Security Number:
_____________________________________
Age: ________ Sex: _________
Date of Birth: ___________________
Father's Name: _____________________________________________
Mother's Name: ____________________________________________
Father's Occupation:
_______________________________________
Mother's Occupation:_______________________________________
Father's Email: _____________________________________________
Mother's Email:_____________________________________________
Father's work telephone:____________________________________
Mother's work telephone:____________________________________
Address of either parent
if different from above: Mother Father
____________________________________________________________
INTERNATIONAL STUDENTS
Name as it appears on
Passport:
_________________________________________________________
Country of birth: _________________________________________
Country of Citizenship:
___________________________________
Number of Years Studying
English _________________________
Do you need a student
visa? ____yes ____no
ACADEMIC INFORMATION
Name of Present School:
_______________________________________
Address of Present School:_____________________________________
Telephone: __________________
Director/Principal: _______________
Applying For: 8th ______9th______10th____11th_____
12th_____
Grade. Grade Point Average:
______
Has applicant ever been:
accelerated ___ suspended
___ expelled ___
given remedial help ____________
received special education
services____ been on 504 plan____ ?
MEDICAL INFORMATION
Please describe on a
separate sheet of paper
any disability or medical
condition that may affect the applicant's
ability to fully participate
in the academic and/or other programs
provided at our school.
Has the applicant ever
been through any form of
educational or psychological
assessment by a professional?
What were the results
of the testing and the prescribed course of action?
lease use separate sheet
of paper.
Has or is the applicant
taking any medication regularly?
(i.e. insulin, dilantin,
ritalin) Yes No If yes,
explain: ____________________________________________________
Does applicant have any
allergies? ____Yes ____No
If yes, list: _________________________________________________
Our school will maintain,
in conformance with the
Family Educational Rights
and Privacy Act, the confidentiality
of any information provided.
AFTER SCHOOL PROGRAM
Heritage Academy does
not discriminate on the basis of race,
religion, sex, or national
origin. By signing below I certify the
information provided
on this application is accurate and true to
the best of my knowledge.
Signature of applicant_______________________________________
Signature of parent or
guardian______________________________
This application must
be accompanied by a non-refundable
US$50 application fee
payable to Nyskc Golf
School of Goshen
Credit Card Type ( Visa/
MC only) Card #_____________________
Exp Date_________________Name
on Card_____________________
Authorization Signature______________________________________
Amount authorized to
be charged by Heritage Academy
US$_______________
Please refer all questions
to: Daniel Y. Kim 718-706-6727 |
