Greater New York Academy of Seventh-day Adventists And al l thy children shall be taught of the Lord. Isaiah 54: 13

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1 APPLICATION: Signature of Guarantor (parent or guardian) GENERAL RECOMMENDATION Applicant: / / / Last Name First Name Middle Initial Date Home Address: / / / Number & Street Name City State Zip Code TO THE RESPONDENT: Your evaluation of the above mentioned individual to Greater New York Academy will be appreciated. Because we need your candid appraisal of this individual, the evaluation form will be destroyed after it has served its admission purpose. Please mail to Greater New York Academy Admission Office at th Street, Woodside, NY Thank You. ABOUT THE SCHOOL: Greater New York Academy is a Seventh-day Adventist institution of secondary education where highest priority is given to maintaining a campus environment favorable for the religious, intellectual, social and physical development of students, and to providing association for students with socially and religiously compatible young people who accept or are willing to abide by the moral and ethical standards of the Christian faith as understood by the Seventhday Adventist Church. Please rate the applicant in the following areas: CHARACTERISTICS UNDESIRABLE ACCEPTABLE DESIRABLE Honesty Attitude Toward Religion Choice of Associates Influence on Associates Academic Motivation Emotional Stability Attitude to Authority I recommend acceptance without reservation. I recommend acceptance with reservation (please comment). I cannot recommend at this time (please comment) I would prefer talking with you personally about this applicant. Tel. #: ( ) COMMENTS: Date: Signature: Position: Name of School or Business: Address:_ PLEASE RETURN TODAY

2 APPLICATION: PASTOR S VERIFICATION LETTER Dear Parent: The Greater New York Academy is a Seventh-day Adventist educational institution, supported by the Seventhday Adventist Church. Since our school is subsidized by Greater New York Conference, a special tuition rate is available to members of the Seventh-day Adventist Church. To qualify for this rate, it is necessary to establish your church membership affiliation each year. Please have the form below completed and signed by the Pastor of your church. Return this letter to Greater New York Academy by July 31 st (late registrants who register in August must return this letter before the first day of school). If this form is not returned by the date specified, the non-discounted tuition amount will be billed to your account. However adjustments will be made on the first of the month following receipt of this letter. We are not able to make retroactive adjustments. Thank you for your cooperation and assistance. Sincerely, L. Mitchell Claudia Valcin Principal Business Manager This is to certify that (Name of Parent) Parent/guardian of (Name of Student) Is a member of the (Name of Church) In the (Name of Conference) Pastor s Signature Date Comments:

3 Incoming APPLICATION: STUDENT INFORMATION FORM Date: / Returning Student ID Number Class of GNYA ID # Please provide the following information in the space below. You will not be unable to complete registration until you are able to provide the requested information. Student: (Last Name) (First Name) (Middle Initial) (Date of Birth) (#, Street, Apt.) (City, State, Zip Code) (Telephone #) (Sex) (Today s Date) Religion: Seventh-day Adventist: Yes No Name of SDA Church Baptized: Yes No Conference: (Check One ) GNYC Northeastern Other Primary Responsible Party: (The individual with whom you reside) (Last Name) (First Name) (Title: Mr./Mrs./Ms.) (Street. No. & Apt. #) (City, State, Zip Code) (Home Telephone #) (Cell #) (Work Tel. #) (Ext.) Secondary Responsible Party: Relationship to Student: (Last Name) (First Name) (Title: Mr./Mrs./Ms./Dr./Pr.) _ (Street, No., Apt. #) (City, State, Zip Code) _ (Home Telephone #) (Work #) (Ext.) (Cell #) Class Schedule: (to be completed by Guidance Counselor or Designated Official) First Semester (Fall) Second Semester (Spring) Mon. 1 St Period Mon. 1 st Period & 2 nd Period & 2 nd Period Wed. 3 rd Period Wed. 3 rd Period 4 th Period 4 th Period Tues. 1 St Period Tues. 1 st Period & 2 nd Period & 2 nd Period Thu. 3 rd Period Thu. 3 rd Period 4 th Period 4 th Period Signature of Guidance Counselor or Designated Official

4 APPLICATION: SPECIAL PRIVILEGE REQUEST FORM SPECIAL PRIVILEGE REQUEST FORM Student s Name: Gender ( M / F ) DOB Grade: Please indicate if your child has a Physician verified allergy to any of the following. If yes, please provide official documentation by your child s physician at the beginning of the school year to the Registrar s office. Bee Stings Peanuts Nuts Other Food Medication(s) Describe your child s reaction Emergency Care Plan Other Allergies: Please list:,, Does your child carry medication with him/her Yes No _ Name of Medication Name of Medication Reason Home School Does your child need Special Bathroom Privilege Yes No. If yes, please explain This request will be: Annual Temporary If temporary, when will privilege terminate (Give Date) Note: This request is valid for one school year only. All medical requests require a doctor s note for the request to be granted. In order to promote maximum exposure of our students to educational activities it is important that they be present for the entire class period. If circumstances develop throughout the school year, please inform the school in writing of your child s needs. Date Parent/Guardian Name (please print) Parent/Guardian Signature

5 APPLICATION: Photograph/Name Release for School Publication Photograph/Name Release for School Publications The Greater New York Academy is desirous to maintain a high level of security regarding the use of only authorized photographs on our web site, as well as on printed publications. Greater New York Academy desires to use individual photograph or group photograph from the faculty and students in our publications. Your signature below authorizes GNYA to use your photograph, and possibly your name on the school web site and publications. The following is a request for permission to use your name and/or photograph. Please check the appropriate blank(s), sign and return it to the office as soon as possible. Name: (No personal information such as home address or telephone numbers will be used in these publications) NAME RELEASE: I give permission for my first name ONLY to be featured in GNYA publications. I give permission for my full name ONLY to be featured in GNYA publications. I do not give permission for my name to be featured in GNYA publications. PHOTO RELEASE: I give permission for my photograph and/or other illustrating material to be featured on the school s website and other publications. No, I do not give permission for my photograph and/or other illustrating material to be featured on the school s website and other publications Parent/Guardian Signature Date

6 APPLICATION: Physical Education and Extra Curricular Athletic Events CONSENT FORM We the undersigned parent(s) and/or guardian of Student s Name Consent to let my child, participate during the present school year in Physical Education and other Extra Curricular Athletic Events. My child is not currently being treated for any physical condition that may prohibit participation in such activities. I understand that my child is expected to exercise caution while participating in physical activities in order to prevent injuries, and that if an injury should occur, I will be notified as soon as possible. Signature of Father/Guardian Date Signature of Mother/Guardian Date

7 APPLICATION: CONSENT TO TREATMENT AND HEALTH INSURANCE INFORMATION Student s Name (print or type) Social Security # Date of Birth Grade Home Address: Tel. #: Allergies: Date of the Last Tetanus Booster: ( five years or less) Name of Doctor Tel: # I/We, the undersigned parent(s) or guardian(s) of the above named student, do hereby consent to any X-Ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital service that may be rendered to said student under the general or special instructions of any physician Greater New York Academy may call, whether such diagnosis or treatment is rendered at the office of said physician or at a licensed hospital. It is understood that reasonable effort will be made to contact the doctor listed above before any other physician is called by the school or other organization. It is further understood that this consent is given in advance of any specific diagnosis or treatment which might be required and is given to authorize Greater New York Academy and the physician to exercise their best judgment as to the requirements of such diagnosis or treatment. If the insurance company does not cover services, or if I/we do not have insurance, I/we agree to take full responsibility of all financial obligations incurred during treatment and/or hospitalization of the student. Parent(s)/Guardian(s) are responsible for any co-payment at the time of service. This consent must be updated annually and/or immediately in the event of changes in insurance information. A Photocopy of this authorization shall be considered as effective and valid as the original. Mother/Female Guardian Name Social Security # Father/Male Guardian Name Social Security # Address Address City State Zip Code City State Zip Code Home Tel # Cell # Work # Home Tel # Cell # Work #

8 APPLICATION: CONSENT TO TREATMENT AND HEALTH INSURANCE INFORMATION Insurance Information Name of Insured: Employed By: Date of Birth: Policy #: Group #: Insurance Co.: Ins. Co. Address: Ins. Co. Tel. #: Student s Primary Care Physician Physician s Name: Address: Insurance Information Name of Insured Employed By: Date of Birth: Policy #: Group # Insurance Co.: Ins. Co. Address: Ins. Co. Tel. #: Secondary Physician/Specialist Physician s Name: Address: City, State, Zip Code: Telephone #: City. State, Zip Code: Telephone #: Student s Emergency Contact (If Parent/Guardian Unavailable) Name: Relationship: Address: City, State, Zip Code Home Telephone #: Cell Phone #: Name: Relationship: Address: City, State, Zip Code: Home Telephone #: Cell Phone #: IF THE STUDENT IS A FEMALE AND UNDER 18 I do grant permission for a pelvic examination without written consent if a medical situation arises. I do not grant permission for a pelvic examination if a medical a situation arises.