Application for Admission – pinecobble.org

Student Information

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Student's Full Name(Required)

First Middle Last

Old field. Not being deleted to maintain entries.

First Name(Required)

Student’s First Name

Middle Name(Required)

Student’s Middle Name

Last Name(Required)

Student’s Last Name

Date of Birth(Required)

Student’s Date of Birth

Gender(Required)

Student’s Gender or Gender Identity

Age(Required)

Student’s Age

Pronouns

Student’s Preferred Pronouns

Preferred Name

Student’s Preferred Name

School Year Applying For(Required)

Grade Applying For(Required)

(Our Beginners Program Starts at 2 Years 9 Months Old)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Current School Information

Name of Current School(Required)

Student’s Current School (if applicable)

Current Grade(Required)

Student’s Current Grade

Number of Years at Current School(Required)

(if applicable)

Address of Current School

Street Address Address Line 2 City State ZIP Code

(if applicable)

Phone Number of Current School(Required)

(if applicable)

Homeroom Teacher(Required)

First Last

(if applicable)

Parent/Guardian/Caregiver Information

Parent/Guardian/Caregiver's Full Name(Required)

First Last

Additional Parent/Guardian/Caregiver's Full Name

First Last

Copy on Correspondence(Required)

Yes

Copy on Correspondence

Yes

Address(Required)

Street Address Address Line 2 City State ZIP Code

Address

Street Address Address Line 2 City State ZIP Code

Email Address(Required)

Email Address

Home Phone Number

Cell Phone Number(Required)

Cell Phone Number

Occupation/Job Title(Required)

Occupation/Job Title

Employer/Business Name(Required)

Employer/Business Name

Employer/Business Address

Street Address Address Line 2 City State ZIP Code

Employer/Business Address

Street Address Address Line 2 City State ZIP Code

College/University Attended

(if applicable)

College/University Attended

(if applicable)

Additional Student Information

Student's Extracurricular Activities, Hobbies, and Special interests:(Required)

Has the student ever had any educational, psychological or neurological evaluation(s)?(Required)

Yes

Has the student ever been expelled, contract non-renewed, or requsted to withdraw from any school?(Required)

Yes

If "Yes," please explain.(Required)

Are There Other Children in the Family?

Second Child's Full Name

First Last

Age

Second Student’s Age

Current Grade

Second Student’s Current Grade

Current School

Second Child’s Current School

Third Child's Full Name

First Last

Age

Third Child’s Age

Current Grade

Third Child’s Current Grade

Current School

Third Child’s Current School

Fourth Child's Full Name

First Last

Age

Fourth Child’s Age

Current Grade

Fourth Child’s Current Grade

Current School

Fourth Child’s Current School

How Did You Hear About Pine Cobble?

Sources(Required)

From a Friend or Aquaintence

From a Family Member

On Social Media

At Community Event

Saw Information on a Flyer

Saw Summer Camp Publications

Received a Mailing

Name of Source

First Last

Name of Source

First Last

Your Name

Name of Caregiver or Responsible Adult Completing this Application

In consideration of the undertaking of Pine Cobble School to process this application and related forms, I hereby agree that the information furnished on this form, together with all information and materials of any kind received by Pine Cobble School from any source, or prepared by anyone at the School’s request, shall be confidential and shall not be disclosed to anyone, including me and my family, except as the Head of School may, for official purposes and at his/her discretion, disclose any part thereof to such person or persons as deemed advisable.

Acknowledgement(Required)

I declare that the information reported on this form, to the best of my knowledge and belief, is true, correct, and complete at the date of this application. I am submitting herewith the non-refundable application fee of $45.00 via credit / debit card.

Total

Credit Card(Required)

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

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