Student Information

Student’s Name:        Nickname:
Street Address (line 1):
Street Address (line 2):
City:        State:        Zip Code:
Mailing Address (if different from above) (line 1):
Mailing Address (if different from above) (line 2):
City:        State:        Zip Code:
Home Phone:        Fax:
E-mail Address:
Date of birth:        Birthplace:
Last School:        Grade Completed:
School Street Address:
City:        State:        Zip Code:
Has the student ever repeated a grade?   Yes    No
If so, which grade and why? (You may use approximately 100 characters.)

Special interests (music, photography, sports, et cetera) (You may use approximately 100 characters.)

After filling out this page print it and complete it by signing it below.

If accepted to and enrolled in Freedom Mountain Academy, I agreed to abide by its Honor Code and to make my best effort be a contributing member of the student body at all times.

Name of Student (print): ________________________________________

Signature of Student: __________________________ Date: __________