Application for Admission (K-12)

Entering Grade:

School Year: --

Today's Date:

Name of Applicant

First: Middle: Last:

Nickname:

Home Address

Address:

City: State: ZIP:

Phone:

Date of Birth:

Family Information

	Parent (or Guardian)	Parent (or Guardian)
Name in Full:
Address: if different from above
	City:	City:
	State: ZIP:	State: ZIP:
Home Phone:
E-mail:
Fax:
Employer/Position:
Business Address:
Business Phone:

If parents are separated, with whom does the student live?

If separated, which parent will assume financial responsibility for the applicant?

Are you applying for financial aid? Yes No

(Financial aid is awarded on the basis of a parent's financial statement. This form will be mailed to you if you checked "yes.")

School Information

Applicant's Current School: Current Grade:

Address:

City: State: ZIP:

Telephone:

References

Please list names of teachers you have asked to provide academic references. List two references if you are applying for Kindergarten-Grade 4. List current math, English and science teachers if applying for grades 5-12.

Name:

Subject and/or Grade Level:

Address:

Telephone:

Name:

Subject and/or Grade Level:

Address:

Telephone:

Name:

Subject and/or Grade Level:

Address:

Telephone:

Please list any relatives who attend, or have attended, Canterbury School:

Name of Relative	Date of Attendance	Relationship to Applicant

Has applicant visited Canterbury School?

Yes

If yes, when?

Has applicant applied to Canterbury School in the past?

Yes

If yes, when?

Canterbury School was recommended by

How did you learn of Canterbury School? Why have you chosen to apply? (Student or parent may complete.)

List sports, hobbies, musical, artistic or other talents of the applicant and his/her time commitment to them:

If the applicant requires special accommodations, please identify them.

If applicant has had aptitude/achievement testing or diagnostic evaluation other than at school, please enclose a copy with your application fee, or indicate where we may write for full information.

What you would like the Canterbury admissions director to know about the applicant that has not been covered on this application?

This application is a statement of parental intent, not a contract. A formal contract must be signed after the applicant is accepted for admission. This application is not considered complete until the applicant has been tested and interviewed by the school. A nonrefundable fee of $75 must be sent to the admissions office for Kindergarten. A fee of $35 is required for grades 1-12.

Please press the reset button to clear the application or the submit button to submit your application.

Thank you for your interest in Canterbury School! Please feel free to contact the following for more information.

Kindergarten-Grade 8	Grades 9-12
Krista Lohmar Canterbury School 5601 Covington Road Fort Wayne, IN 46804 (260) 407-3553 Fax (260) 407-3551	Susan Johnson Canterbury School 5601 Covington Road Fort Wayne, IN 46804 (260) 407-3553 Fax (260) 407-3551