Father Information Father's Middle Name (if any): Father's Email Father's Phone Mother Information Mother's Middle Name (if any): Mother's Email Mother's Phone: Other Information Primary Email Address for Contact Purposes: * Parent's Languages * Parent's Preferred Language * Student Information Student's Middle Name (if any): Name and Ages of Student’s Siblings: Countries the Student has lived in: Explain why you would like your child enrolled in the boarding program: Have you read the entire Residence Life handbook? How do you feel about the values and guidelines explained in the Residence Life handbook? Are you willing to fully support all aspects of the residence life handbook? If not, which ones can you not support? How do you expect your child will adjust to dorm life? What will be your child’s strengths related to community living? What will be your child’s weaknesses related to community living? How do you expect your child will contribute to a Christian home environment in the dorm? How do you expect your child to adjust to living with students from a variety of cultural backgrounds? How do you plan to manage the separation from your child? Do you think your child will need help functioning in English in the dorm? If yes, how much extra support will he/she need? How would you describe your child’s study habits? Has your child ever been diagnosed with a learning, behavioral or emotional disability or any other disability? If yes, please explain. Does your child have a history of any behavioral problems? If yes, please explain. Has your child ever been under discipline at a former school or program, including suspension or expulsion? If yes, please explain. Has your child ever been involved in or had experiences with any of the following: If yes, please explain: Does your child have any other issues not listed above that would affect their adjustment to boarding life? If yes, please explain. List any medical issues or problems your child has experienced (migraines, allergies, asthma, fainting, stomach issues, etc.) List any childhood diseases your child has experienced (i.e. – chicken pox, diabetes, epilepsy, etc.) List any major injuries or surgeries your child has had. Is your child currently taking any kind of medication? If yes, please explain. Is your child presently under a physician’s care for any reason? If yes, explain. Has your child experienced any major crisis or trauma, either physically, emotionally, or socially? If yes, please explain. Has your child ever struggled with any emotional problems (i.e. – anxiety, depression, addiction, eating disorders, self-harm, running away, etc.) If yes, please explain. Has your child ever met with a counselor, psychologist, or psychiatrist? If yes, please explain. Is your child presently under the care of a counselor, psychologist, or psychiastrist? If yes, explain. Has your child ever taken any medication for emotional or behavioral problems (i.e. – ADD/ADHD, anxiety, depression, etc.)? If yes, please explain. Would you like your student to meet regularly with a staff mentor?
(This is an optional program offered to dorm students.)
What other information about your child or family background would be helpful for dorm parents to know? Affirmation
I affirm that all the answers and information provided on this application are true and complete to the best of my knowledge.
The below signature/name is for: *