______________________________________________________ _________________________________________________
Brothers and Sisters (names and current grade in school)___________________________________________________
___________________________________________________________________________________________________
Check if appropriate ____ Father ____ Mother ____ Parents ____ Parents ____ Father ____ Mother
Deceased Deceased Divorced Separated Remarried Remarried
If any one of the above is checked, please give full name, relationship, and address of parent(s) or guardian(s) with whom
applicant legally resides and to whom School correspondence should be sent:
Name___________________________________________________ _______________________________
Last First Middle Relationship
Address____________________________________________________________________________________
Street City State Zip
If parents are divorced or separated, please indicate who has legal custody of applicant.
____Father ____Mother ____Both Parents ____Other_______________________________________________
Name Address Phone
PERSONAL INFORMATION
Name of relatives(s) or friend(s), if any, now or formerly at Stuart Hall (name, class)______________________
__________________________________________________________________________________________
Has the applicant skipped or repeated a grade? Please explain.________________________________________
__________________________________________________________________________________________
Does the applicant have any health or emotional needs that the School will need to address? Is the applicant
experiencing emotional or behavioral difficulty at present?____________________________________________
___________________________________________________________________________________________
Has the applicant ever received counseling and if so, when?___________________________________________
A full disclosure report is required. Please have the report sent to Admissions.
Has the applicant ever been dismissed, asked to withdraw, or withdrawn from school for any reason, including
medical or emotional reasons? Please explain the circumstances.______________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Does the applicant have any diagnosed/documented learning disabilities the School should be aware of? A full
disclosure report is required. Please have the report sent to Admissions.
__________________________________________________________________________________________
Has the applicant ever tried to harm him/herself?___________________________________________________
Has the applicant ever been in a residential treatment program?________________________________________
Does the applicant currently use tobacco products?__________________________________________________
Does the applicant have a history of substance abuse?________________________________________________
Has any previous school attendance been interrupted by illness at any time for longer than a two-week
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