51

West Cliff Street

Somerville, NJ 08876
Phone: 908-218-4100
Fax: 908-526-9668

OFFICE USE ONLY

Complete App Recd

Date Attended Parent Info Session

Somerville Medical Science Academy

Application for Full Time Admission for School Year 2015-16

LAST NAME





HOME ADDRESS

FIRST NAME

MIDDLE NAME

STATE ZIP

MALE FEMALE

CITY

HOME PHONE NUMBER

*GUARDIAN 1 NAME



GUARDIAN 1 EMAIL

DAYTIME PHONE # CELL PHONE #

GUARDIAN 1 RELATIONSHIP TO STUDENT

*GUARDIAN 2 NAME



GUARDIAN 2 EMAIL

DAYTIME PHONE # CELL PHONE #

GUARDIAN 2 RELATIONSHIP TO STUDENT

IF THE STUDENT DOES NOT RESIDE WITH BOTH GUARDIANS, WHICH GUARDIAN DOES THE STUDENT LIVE WITH?

____________________________________________________________________________________________


I hereby authorize the sending school district to make available all scholastic, health and psychological records
pertaining to my child. In the event on an emergency, permission is granted to transport my child to the Somerset
Medical Center.

PARENT SIGNATURE (REQUIRED) DATE
SOMERVILLE PUBLIC SCHOOL DISTRICTS AFFIRMATIVE ACTION POLICY

To provide equal educational opportunities regardless of sex, race, color, religion, ancestry, national origin, age, sexual orientation,
handicap, or social/economic status. Contact Melissa McCooley, Title IX & Affirmative Action Officer, 908-218-4118. Inquiries
regarding Section 504, Rehabilitation Act of 1973 (PL 93-112) contact Joanne Sung, 504 Coordinator, 908-218-4118.

SENDING DISTRICT INFORMATION

STUDENTS NAME

RESIDENT SCHOOL DISTRICT

CURRENT SCHOOL ATTENDING

CURRENT SCHOOL ADDRESS

CURRENT SCHOOL PHONE NUMBER

AND COUNSLEOR EXTENSION
ATTENDANCE RECORD:
GRADE 7

DAYS ABSENT
st

nd

GRADE 8 (1 and 2 MARKING PERIODS)

DAYS TARDY

DAYS ABSENT

DAYS TARDY

CHECK HERE IF THIS STUDENT HAS BEEN CLASSIFIED BY THE CHILD STUDY TEAM
CHECK HERE IF THIS STUDENT HAS BEEN DE-CLASSIFIED BY THE CHILD STUDY
TEAM CHECK HERE IF THE STUDENT HAS A 504 PLAN (IF SO, PLEASE ATTACH)

CHECK HERE IF THE STUDENT IS RECEIVING ESL SUPPORT SERVICES

WHAT IS THE PRIMARY LANGUAGE SPOKEN AT HOME?
DISCIPLINE RECORDS (Log) :

YES

NO

X
PRINCIPAL OR VICE PRINCIPALS NAME (PRINT)
SIGNATURE
(Signature along with response above verifies discipline record)

NOTE: All items in the checklist below MUST be submitted in order to process the student application. Incomplete applications will
be returned to the counselor for completion.
SENDING DISTRICT COUNSELORS CHECKLIST

7TH GRADE TRANSCRIPTS

PARENT SIGNATURES

TH

DATE

8 GRADE TRANSCRIPTS

COPIES OF ACHIEVEMENT TEST SCORES

ATTENDANCE RECORDS

TEACHER RECOMMENDATION FORMS

NJ STATE I.D. NUMBER

DISCIPLINE RECORDS ENCLOSED (Log)*

*If student has no discipline record, please check

and initial here:

HEALTH HISTORY & APPRAISAL FORM A-45

I VERIFY THAT THE FOLLOWING INFORMATION IS COMPLETE AND ACCURATE

REQUIRED: COUNSELORS NAME (print)

SIGNATURE

E-MAIL

DATE

Applicants Name:
________________________________________________________________________________________


Share an important or difficult decision you have made within the past two years. Describe the situation and
discuss what you have learned about yourself and/or others. (Please feel free to attach additional sheets of
paper, if necessary.)