Akolouthia Institute - Grades 7-12 Student Application

Akolouthia Institute Grade 7-12 Student Application

APPLICATION PROCEDURES

Please complete the entire application form and submit on-line by pressing the "Submit" button below.

PERSONAL INFORMATION

Akolouthia Institute admits students regardless of race, color, religion, gender, age, national and ethnic origin, disability, or sexual orientation.

Applicant's First Name

Last Name

M.I.

Preferred Name/Nickname

Address
City		State		Zip		County

Home Telephone				Family Email
Date of Birth (M/D/Y)				Gender.		Female	Male

Student Lives With (check all that apply)

Father

Mother

Stepfather

Stepmother

Other

Check if Appropriate

Father deceased

Mother Deceased

Parents Divorced

Parents Separated

Name of parent/guardian applicant lives with:

Languages spoken at home:

First :

Second:

SCHOOL INFORMATION
Present School Grade:
School Address

School City

State

Zip

County

Telephone: Name of principle or guidance counselor:

Has the applicant applied to Akolouthia Institute before: No Yes Date:

Has the applicant ever:

repeated a grade	No	Yes	If Yes, grade
skipped a grade	No	Yes	If Yes, grade

Have you ever been requested to withdraw from a school? No Yes Date:

For what Reason?

Has this student ever had psychological testing or been screened for academic difficulties or

learning disabilitites: No Yes If yes, would the results be available to us? No Yes

OTHER INFORMATION

How were you referred to Akolouthia Institute?

AI Open House

Mail from AI

Newspaper

Internet

By a current AI family (name:)
Referred by:
Other


Areas of Interest :
Special Interests
Performing Arts - List activities
Visual Arts - Describe
Computer Science/Technology
Other - Interests /Hobbies

FAMILY INFORMATION

Father/Guardian:		Mother/Guardian:
Home Address (if different from Applicant's)		Home Address (if different from Applicant's)
Home Phone		Home Phone
Mobile Phone		Mobile Phone
Position or Title		Position or Title
Company		Company
Company Address		Company Address
Occupation		Occupation
Bus. Phone		Bus. Phone
E-Mail Address		E-Mail Address
Education - Schools Attended		Education - Schools Attended

Sibling Information

Sibling 1 Name	Current Grade
Relationship to AI: None Current AI Student Previous Student Also Applying
Sibling 2 Name	Current Grade
Relationship to AI: None Current AI Student Previous Student Also Applying
Sibling 3 Name	Current Grade
Relationship to AI: None Current AI Student Previous Student Also Applying

Other Relatives

Other relatives who've attended Akolouthia Institute:

Paternal Grandparents Name		Maternal Grandparents Name

Address		Address
City		City
State	Zip	State	Zip

APPLICANT STATEMENT

By submitting this application we understand and agree that tuition for enrolled students is due in full by the date(s) posted on the official Akolouthia Institute website, and that after that date no portion of such fees so paid or out-standing will be refunded or canceled notwithstanding the subsequent absence, withdrawal or dismissal from the School of the above student. The undersigned certify that information contained in this application is true and complete. The undersigned understand that false information may be grounds for not accepting the applicant or for immediate termination of matriculation and any point in the future if the applicant is accepted. The undersigned authorize the verification of any or all information listed above. The undersigned further agree that all school records and information pertaining to the application of the named student to Akolouthia Institute shall be completely confidential and shall not be disclosed to anyone, including the student and his/her family. The undersigned, on behalf of the above named student and his/her parents or guardians, further agree not to seek access to such confidential information, including recommendations and evaluation materials before or after completion of the admission process for the above named student.
Acklowledgement of both parents or guardians required.

Parent Guardian	Date

Parent Guardian	Date

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