Student Information
Contact information and academic history…
Family Information
Guardian and emergency contact information…
Medical Information
Emergency and medical information…
Sign & Submit
Sign and submit the application for admission…
Student Details
First Name
Middle Name
Last Name
Preferred Name
Social Security #
Birth Date
Birth Place
Age
Sex
Race
Contact Informaiton
Street Address
City
State
Zip
Home Phone
Cell Phone
Academic History
Name/Address of Last School Attended
Last Grade Attended
Grade Applying For
Has student ever repeated grades, been dismissed or suspended at any school?
If yes to above, please provide brief description of circumstances.
Family Information
Does the student live with both parents?
If no to above, please check one of the following.
Father’s Information
Father’s Name
Father’s Place of Employment
Father’s Work Phone
Father’s Academic Level
Mother’s Information
Mother’s Name
Mother’s Place of Employment
Mother’s Work Phone
Mother’s Academic Level
Guardian/Stepparent’s Information
Guardian’s Name
Guardian’s Place of Employment
Guardian’s Work Phone
Guardian’s Academic Level
Grandparent’s Information
1st Grandparent Name
1st Grandparent Address
2nd Grandparent Name
2nd Grandparent Address
Sibling Information (Siblings Attending BCA Only)
1st Sibling Name
1st Sibling Grade
2nd Sibling Name
2nd Sibling Grade
3rd Sibling Name
3rd Sibling Grade
Medical Information
Does this student have a physical disability or handicap?
If yes to above, please provide brief description of the physical disability or handicap.
May this student be given a non-aspirin pain reliever such as Tylenol or Ibuprofen?
Health Questionnaire
Does your child have an unusual health conditions?
Check any health conditions that apply to your child…
If Other checked above, please provide brief description of the condition.
Insurance Information
Insurance Company
Policy Number
Insured’s Name
ID Number
Family Physician
Family Physician’s Name
Office Phone
Family Dentist
Family Dentist’s Name
Office Phone
Emergency Treatment & HIPAA Release
In the event that my child experiences a medical emergency and I cannot be immediately reached: 1) The Academy may contact the above-listed physician or dentist, 2) The Academy upon the direction of said physician or dentist or upon their unavailability may transport my child to the emergency room for immediate treatment, and 3) The Academy is authorized hereinto by this release to have access to all “HIPAA” protected information pertaining to the treatment of my child for the pending emergency and may so communicate freely concerning this information with any physician, dentist, nurse or healthcare staff member.
Parent/Guardian Signatures
By signing below, I certify that the information provided in this application is true and accurate to the best of my knowledge. Furthermore, I understand that it is my responsibility to immediately notify the administrative office of BCA if any changes to the information represented in this application occur.
