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APPLICATION FOR ADMISSION
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PERSONAL INFORMATION
First Name
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Middle Name
Last Name
Date
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Option 1
Option 2
Age
Place of Birth
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Home Address
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Home Telephone #
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Child's NIB #
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Email Address
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Name of Current School
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State the last grade level completed
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Guardian Information
Mother's/Guadian's Name
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Person to Contact for Emergencies
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Telephone # for Emergency Contact Person
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Does your child have any of the following? Select all that apply
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Physical Disability
Other Disabilities
Learning Needs
Allergies
If your child has other disabilities please list and explain?
Please provide name, address, email and telephone numbers of person responsible for the student's financial account
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I affirm that the information submitted on this completed application form is correct, including all copies supporting documents. I full understand that submission of false information may result in the non acceptance or withdrawal from Ebenezer College Virtual Smart School. If you agree with this statement PLEASE WRITE YOUR NAME IN THE SPACE BELOW AND THEN PRESS THE SUBMIT BUTTON
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