Online Teacher Recommendations


Records Release Form

Please complete this form and give it to the registrar at your current school:


Online Application

 Parent's Portion

STUDENT INFORMATION
STUDENT INFORMATION
Address
Address
NA
Gender
Applicant for Grade
Date of Application
Date of Application
Student Date of Birth
Student Date of Birth
Home Telephone
Home Telephone
Cell Phone
Cell Phone
Ethnicity
For U.S. Citizens: I consider myself to be a member of the following racial or ethnic group:
ACADEMIC HISTORY
School Address
School Address
School Telephone
School Telephone
School Fax
School Fax
Has the applicant ever been expelled or dismissed from school?
Has the applicant ever been suspended from school?
Please list all schools attended since Grade 1 | SCHOOL NAME, YEARS ATTENDED
Testing
In addition to standardized group testing, such as the Secondary School Admission Test (SSAT), Independent School Entrance Exam (ISEE), or High School Placement Test (HSPT), has the student ever had individually administered intelligence or achievement testing?
Class Absence(s)
In the last three years, has the student missed more than five consecutive days of school?
If your child has missed more than five consecutive days of school please explain...
Has the applicant previously applied to Middleburg Academy?
Has the applicant previously visited Middleburg Academy?
FAMILY INFORMATION
Parent 1
Parent 1 is
Parent 1
Parent 1
Parent 1 Address
Parent 1 Address
Parent 1 Cell Phone
Parent 1 Cell Phone
Parent 1 Home Telephone
Parent 1 Home Telephone
Preferred Contact Time(s)
Work Place Address
Work Place Address
Work Place Phone Number
Work Place Phone Number
Please provide SCHOOL NAME, LOCATION, GRADUATION YEAR
Education: College or Post-Secondary School. | Please provide SCHOOL NAME, LOCATION, GRADUATION YEAR
Please provide SCHOOL NAME, LOCATION, GRADUATION YEAR
Parent 2
Parent 2 is
Parent
Parent
Parent 2
Address
Address
Parent 2
Home Telephone
Home Telephone
Parent 2
Parent 2 Cell Phone
Parent 2 Cell Phone
Preferred Contact Times
Parent 2
Employer's Address
Employer's Address
Parent 2
Employer Telephone
Employer Telephone
Parent 2
Parent 2
Marital Status
If divorced/separated, which parent has legal custody?
Correspondence
To whom should correspondence be sent?
If billing information is different, to whom should it be sent?

Student Questionnaire

Student's Name *
Student's Name
Student's Address
Student's Address
List any awards or recognition you have received in the past two years. Attach an activities sheet if necessary
Please use the following space to write a short autobiography. This section should be completed solely by the student applicant.