St. Andrew welcomes your family to ours. When you come by to meet with us,
please be prepared to tell us a little more about yourself, your child, and what brings you to us.
The Teaching Ministry Of
St. Andrew Missionary Baptist Church Private School Parent Coop Prayer Clinic APPLICATION Family Information Student’s Name________________________________________________________________________________ Last First Middle Applying for grade:___________________ Date of Birth:_______________________________________________ Name by which student prefers to be called:__________________________________________________________ Home Address:_________________________________________________________________________________ Street Apt. # City Zip Code Father’s Name:_________________________________________________________________________________ Home Address:_________________________________________________________________________________ (If different from above) Phone Number(s) Occupation:_________________________________ __________________________________________________ Business Phone Business Address:______________________________________________________________________________ Mother’s Name:________________________________________________________________________________ Home Address:_________________________________________________________________________________ (If different from above) Phone Number(s) Occupation:________________________________ __________________________________________________ Business Phone Business Address:______________________________________________________________________________ Names & Ages of brothers and sisters:______________________________________________________________ _____________________________________________________________________________________________ Candidate’s general health: (Please describe any special conditions of which the school should be aware) _____________________________________________________________________________________________ _____________________________________________________________________________________________EDUCATIONAL BACKGROUND Current School with dates of attendance_____________________________________________________________ Address of School______________________________________________________________________________ Street City Zip Presently enrolled in grade:__________________________REFERENCES List the names and positions of two current school references, one of whom should be the present English teacher: Name:________________________________________________________________________________________ Teacher Grade Subject Name:________________________________________________________________________________________ Teacher Grade Subject List the name, address and phone of an adult (other than a relative) who knows the candidate well, from whom the Saint Andrew Missionary Baptist Church Academy & Theological University Parent Corporation, may request a recommendation:____________________________________________________________________________________________________________________________________________________________________________ Date of Application:__________________________________________________ Signature of Parent/Guardian:_____________________________________________________________________ Signature of Candidate___________________________________________________________________________ HOW DID YOU LEARN OF THIS SCHOOL?_____________________________________________________ The Teaching Ministry of theSt. Andrew Missionary Baptist ChurchPrivate School Parent Coop Prayer ClinicIDENTIFICATION AND EMERGENCY INFORMATION To be completed by Parent or Guardian Child’s Name: LAST MIDDLE FIRST Sex Telephone ( ) Address Number Street Apt # City State Zip Birthdate Father’s Name: LAST MIDDLE FIRST Business Telephone ( ) Home Address Number Street Apt # City State Zip Home Telephone ( ) Mother’s Name: LAST MIDDLE FIRST Business Telephone ( ) Home Address Number Street Apt # City State Zip Home Telephone ( ) Person responsible for child: LAST NAME MIDDLE FIRST Business Telephone ------------ Home Telephone---------------- ADDITIONAL PERSONS WHO MAY BE CALLED IN EMERGENCY NAME ADDRESS TELEPHONE RELATIONSHIP PHYSICIAN OR DENTIST TO BE CALLED IN EMERGENCYPhysician Address Medical Plan & Number Telephone ( )---------------------------------------------------------------------------------------------------------------------------------------------------------- Dentist Address Medical Plan & Number Telephone ( )------------- If physician cannot be reached, what action should be taken? v Call Emergency Hospital v Other (Explain):________________________________________________________________________ Names of persons authorized to take child from the facility (child will not be allowed to leave with any person without written authorization from parent/guardian) NAME RELATIONSHIP Time child will be called for: Signature of Parent or Guardian TO BE COMPLETED BY FACILITY DIRECTOR / ADMINISTRATOR Date of Admission: Date Left: CONSENT FOR MEDICAL TREATMENTAs the parent, agency representative or legal guardian, I hereby give consent to ______________________________________________ to provide all emergency dental or Facility Name medical care prescribed by a duly licensed physician (M.D.) or Dentist (D .D.S.) for ____________________________________________ Name This care may be given under whatever conditions are necessary to preserve the life, limb or well being of my dependent. Child:_______________________________________ has the following medication allergies: ____________________________________________________________________________ _______________________ _________________________________ Date Parent signature ______________________________________________________________________________ Home Address ______________________________________________________________________________ Home Telephone Work Telephone ( ) ( ) The Teaching Ministry of the St. Andrew Missionary Baptist Church Private School Coop Prayer Clinic Annual Health Inventory Dear Parents/Guardians: Your child’s health is significant in planning his/her school program. It is important that he/she is feeling at his/her best in order to benefit from school each day. Occasionally, children have health conditions that affect their routine performance at school. It will help us to assist your child if we are aware of his/her unique needs. Please take a moment to complete this form and return it to the Administrative Office. School:____________________________ Teacher:_________________________ Grade:__________ Child’s Name:______________________________________ Age:_____ Birthdate:____________ Parent/Guardian’s Name:___________________ Relationship:______________ Phone:__________ Emergency Contact Person:__________________ Relationship:______________ Phone:__________ Please complete the Health Inventory below by filling in the appropriate boxes.1. When did your child have his/her last visit to the doctor for a physical exam? __Within last year __Between 1 & 2 years ago __Over 2 years ago __ Never 2. What was the reason for the last visit? __A checkup __Illness/injury If illness/injury, please explain: 3. Does your child have a regular doctor? __yes If “yes”, please give name: ___no 4. When did your child have his/her last visit to the dentist for a dental checkup? __Within the last year __Between 1 & 2 years ago __Over 2 years ago __Never 5. What was the reason for the last visit? __ A checkup __ Toothache/injury If illness/injury, please explain: 6. Does your child have a regular dentist? __Yes If “yes”, please give name: __No 7. Has your child ever had a serious accident? __Yes If “yes”, please explain: __No 8. Has your child ever had an operation? __Yes If “yes”, please explain: __No9. Does your child use: hearing aid dental braces/retainers crutches __eyeglasses __walker/braces __other:______________ 10. Does your child have difficulties with? __ speech If yes please explain: __hearing __vision __attention 11. Is your child’s physical activity limited? __Yes __No If yes, is there a doctor’s statement on file with the school? Yes No 12. Has your child had any of the following? Please check: __Allergies (please list) ______________________________ __Asthma __Heart Condition __Tuberculosis __Other lung diseases __Diabetes __ Seizures __Hemophilia __Sickle Cell Anemia __Ear Infections __Rheumatic Fever __Fever over 103 __Juvenile Rheumatoid Arthritis __Upsets easily/Temper Tantrums Frequent colds or flu (more than three a year) __Frequent headaches (more than one per week) __Other__________________ 13. Does your child currently take medication prescribed by a doctor? __ Yes If yes, please write the name of the prescription: __ No 14. Does your child need to bring any medication to school? __ Yes If yes, please write the name of the prescription: __ No 15. Does your child have a condition that could be a school emergency? __ Yes If yes, please explain: __No 16. Is there any additional information that your think is important for the school to know? __ Yes If yes, please explain: __ No 17. I would like to speak with the school office __Yes __No The best time to reach me is: Parent Signature: My telephone number is: THANK YOU VERY MUCH! The Teaching Ministry Of St. Andrew Private School Parent Coop Prayer Clinic Theological & Academic University Record Release Form To:………………………………………………………………………………………………….. School currently/previously attended by student I hereby give my permission for the release of any records of my daughter/son: …………………………………………………………………………………………………… Student’s Name Requested by the St. Andrew Private School Please forward this request to the following address: St. Andrew Missionary Baptist Church PRIVATE SCHOOL PARENT COOP PRAYER CLINIC THEOLOGICAL & ACADEMIC UNIVERSITY 2608 West Street OAKLAND, CA 94612 ATTN: Administrative Office For further information, you may contact the school at (510) 465-8023 Fax to: (510) 465-0725 ____________________________________________________ Parent Signature & Date ____________________________________________________
**Any fields that do not apply to you mark N/A* We encourage you to bring the following: INFORMATION ABOUT YOUR CHILD'S ACADEMIC HISTORY RECORDS FROM THE MOST RECENT SCHOOL YOUR CHILD ATTENDED INFORMATION ABOUT YOUR EXPERIENCE WITH PUBLIC SCHOOL/PRIVATE INFORMATION ABOUT THE NEIGHBORHOOD WHERE YOU RESIDE INFORMATION ABOUT THE FAMILY'S FINANCIAL STATUS/GOALS/NEEDS INFORMATION ABOUT ANY SPECIAL NEEDS YOUR CHILD HAS ANY INFORMATION YOU FEEL WILL GIVE US INSIGHT INTO YOUR CHILD