51 West Cliff Street Somerville, NJ 08876 Phone: 908-218-4100 Fax: 908-526-9668

OFFICE USE ONLY Complete App Recd Date Attended Parent Info Session

Somerville Medical Science Academy Application for Full Time Admission for School Year 2015-16

LAST NAME FIRST NAME MIDDLE NAME HOME PHONE NUMBER MALE FEMALE HOME ADDRESS CITY STATE ZIP

*GUARDIAN 1 NAME DAYTIME PHONE # CELL PHONE # GUARDIAN 1 EMAIL GUARDIAN 1 RELATIONSHIP TO STUDENT

*GUARDIAN 2 NAME DAYTIME PHONE # CELL PHONE # GUARDIAN 2 EMAIL GUARDIAN 2 RELATIONSHIP TO STUDENT

IF THE STUDENT DOES NOT RESIDE WITH BOTH GUARDIANS, WHICH GUARDIAN DOES THE STUDENT LIVE WITH? ____________________________________________________________________________________________ I hereby authorize the sending school district to make available all scholastic, health and psychological records pertaining to my child. In the event on an emergency, permission is granted to transport my child to the Somerset Medical Center.

PARENT SIGNATURE (REQUIRED) DATE SOMERVILLE PUBLIC SCHOOL DISTRICTS AFFIRMATIVE ACTION POLICY

To provide equal educational opportunities regardless of sex, race, color, religion, ancestry, national origin, age, sexual orientation, handicap, or social/economic status. Contact Melissa McCooley, Title IX & Affirmative Action Officer, 908-218-4118. Inquiries

regarding Section 504, Rehabilitation Act of 1973 (PL 93-112) contact Joanne Sung, 504 Coordinator, 908-218-4118.

SENDING DISTRICT INFORMATION

STUDENTS NAME RESIDENT SCHOOL DISTRICT

CURRENT SCHOOL ATTENDING CURRENT SCHOOL ADDRESS

CURRENT SCHOOL PHONE NUMBER AND COUNSLEOR EXTENSION

ATTENDANCE RECORD: GRADE 7 DAYS ABSENT

GRADE 8 (1st and 2nd MARKING PERIODS) DAYS ABSENT

DAYS TARDY

DAYS TARDY

CHECK HERE IF THIS STUDENT HAS BEEN CLASSIFIED BY THE CHILD STUDY TEAM

CHECK HERE IF THIS STUDENT HAS BEEN DE-CLASSIFIED BY THE CHILD STUDY

TEAM CHECK HERE IF THE STUDENT HAS A 504 PLAN (IF SO, PLEASE ATTACH)

CHECK HERE IF THE STUDENT IS RECEIVING ESL SUPPORT SERVICES

WHAT IS THE PRIMARY LANGUAGE SPOKEN AT HOME?

DISCIPLINE RECORDS (Log) : YES NO X PRINCIPAL OR VICE PRINCIPALS NAME (PRINT) SIGNATURE DATE (Signature along with response above verifies discipline record)

NOTE: All items in the checklist below MUST be submitted in order to process the student application. Incomplete applications will be returned to the counselor for completion.

SENDING DISTRICT COUNSELORS CHECKLIST

7TH GRADE TRANSCRIPTS PARENT SIGNATURES

8TH GRADE TRANSCRIPTS COPIES OF ACHIEVEMENT TEST SCORES

ATTENDANCE RECORDS TEACHER RECOMMENDATION FORMS

NJ STATE I.D. NUMBER

DISCIPLINE RECORDS ENCLOSED (Log)* *If student has no discipline record, please check

HEALTH HISTORY & APPRAISAL FORM A-45 and initial here:

I VERIFY THAT THE FOLLOWING INFORMATION IS COMPLETE AND ACCURATE

REQUIRED: COUNSELORS NAME (print) SIGNATURE E-MAIL DATE

Applicants Name: ________________________________________________________________________________________ Share an important or difficult decision you have made within the past two years. Describe the situation and discuss what you have learned about yourself and/or others. (Please feel free to attach additional sheets of paper, if necessary.)