Application

Child #1 First Name:
Child #1 Last Name
#1 Goes By:
#1 Gender
#1 Age
#1 Birthday
#1 Entrance Grade
Child #2 First Name
Child #2 Last Name
#2 Goes By
#2 Birthday
#2 Entrance Grade
Family Member #1 Relationship to Student
Title
First Name FM#1
Last Name FM#1
Work Phone FM#1
Occupation FM#1
Employer FM#1
Cell FM#1
Email Address:
Family Member #2 Relationship to Student
First Name FM#2
Last Name FM#2
Work Number FM#2
Occupation FM#2
Employer FM#2
Cell Number FM#2
Marital Status
Child(ren) live with:
Child #1's Last School Attended. Please include the address
Child #2's Last School Attended. Please include the address.
Has your child ever been suspended or expelled from school?
If you answered yes to the last question, which student was suspended/expelled?
If yes. Why?
Does your family currently hold a membership in a local church?
Church Name
Church Address
Pastor
Have you ever been questioned by authorities concerning child abuse or neglect?
If yes, please explain fully by e-mailing your responce to school@stocktonbaptistchurch.org . Put the name of child #1 in the subject line. Should we expect an e-mail?
Is your child on juvenile court probation or CYA Parole?
Will your child(ren) be able to attend field trips as long as you are notified in advance?
May we contact your family physician if an emergency arises and we cannot contact you?
Doctor's Name
Doctor's phone number
Medical Record Number
Dentist's Name
Dentist's Phone Number
Dentist Medical Record Number
For child #1 - In addition to the California Immunization Record, we need the following health information. Does your child have any of the following? If yes, please explain in detail on a separate e-mail any procedures or medications that we may need to administer.	Hearing Problems Vision Problems Allergies Daily Medications Epilepsy Asthma
Any additional medical needs:
For child #2 - In addition to the California Immunization Record, we need the following health information. Does your child have any of the following? If yes, please explain in detail on a separate e-mail any procedures or medications that we may need to administer.	Hearing Problems Vision Problems Allergies Daily Medications Epilepsy Asthma
Any additional medical needs:
Emergency Contact #1's relationship to student.
Title
Emergency Contact #1's name
Emergency Contact #1's address
Emergency Contact #'1 home phone number
Emergency Contact #1's cell phone
May Emergency Contact #1 pick up the student(s)?
Emergency Contact #2's relationship to student
Emergency Contact #2 Title
Emergency Contact #2's name
Emergency Contact #2's address
Emergency Contact #2's home phone number
Emergency Contact #'2 cell phone number
May Emergency Contact #2 pick up the student

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