MRA - Madison Ridgeland Academy

Application for Admission: 1-12

Applicant for:
*Grade:
*School Year:

*Applicant's Name:
First:
Middle:
Last:
Preferred:

*Home Address:
Number & Street:
City:
State:
Zip:

*Home Phone:	Use xxx-xxx-xxxx format.
*Social Security #:
*Age:
*Sex:	Male Female
*Birthday:
*Place of Birth:

Father's Information:
Full Name
Social Security #:

Address(if different):
Number & Street:
City:
State:
Zip:
Home Phone:	Use xxx-xxx-xxxx format.
E-mail address:
Cell Phone:	Use xxx-xxx-xxxx format.
Employer:
Occupation:
Business Phone:	Use xxx-xxx-xxxx format.
Business Address:

Education:
High School:
College:
Degrees:

Mother's Information:
Full Name:
Social Security #:
Address(if different):
Number & Street:
City:
State:
Zip:

Home Phone:	Use xxx-xxx-xxxx format.
E-mail address:
Cell Phone:	Use xxx-xxx-xxxx format.
Employer:
Occupation:
Business Phone:	Use xxx-xxx-xxxx format.
Business Address:

Education:
High School:
College:
Degrees:

*Student lives with Whom:	Father
	Mother
	Stepfather
	Stepmother
	Guardian

Please check any that apply:	Father Deceased
	Mother Deceased
	Parents Separated
	Parents Divorced

If parents are divorced, who has legal custody?
If parents are divorced or separated, to whom should admissions correspondence be sent?

Please list siblings:
Sibling 1:
Name:
Birthdate:
Age:
Grade:
School:

Sibling 2:
Name:
Birthdate:
Age:
Grade:
School:

Sibling 3:
Name:
Birthdate:
Age:
Grade:
School:

School Presently Attending:
Address:
Telephone:	Use xxx-xxx-xxxx format.

Medical Problems/Physical Impairments of Applicant, If Any:
Special Talents/Interests:

Family Church:
Denomination:

IN CASE OF EMERGENCY, THE TEACHER OR DIRECTOR HAS OUR PERMISSION TO TAKE OUR CHILD TO A HOSPITAL OR DOCTOR FOR TREATMENT. IF WE CANNOT BE REACHED, PLEASE NOTIFY:

*Emergency Contact 1:
Name:
Relationship:
Phone:	Use xxx-xxx-xxxx format.

*Emergency Contact 2:
Name:
Relationship:
Phone:	Use xxx-xxx-xxxx format.

*Emergency Contact 3:
Name:
Relationship:
Phone:	Use xxx-xxx-xxxx format.

I agree to the terms of the disclaimer, and agree that the above information is true and correct to the best of my knowledge.
Yes	No

Madison-Ridgeland Academy admits students of any race, color, national and ethnic origin to all the rights, privileges, programs, and activities generally accorded or made available to students at the school. It does not discriminate on the basis of race, color, national and ethnic origin in administration of its educational policies, admissions policies, athletic and other school administered programs.
Effective for the duration of enrollment at Madison-Ridgeland Academy, permission is hereby given to participate in the Physical Education Program and Field trips of Madison-Ridgeland Academy. I understand and hereby agree that Madison-Ridgeland Academy is not responsible for any accidents that might occur nor any liability that might arise therefrom.

*All items marked with a * are required.