Apply Online : Dakota Adventist® Academy Bismarck ND

Student Contact Information

Name

Preferred Name

Date of Birth

Gender

Grade Entering

Student Citizenship

Address

Primary Phone Number

Secondary Phone Number

Parent #1 Contact Information

Name

Address

Primary Phone Number

Secondary Phone Number

Parent #2 Contact Information

Name

Address

Primary Phone Number

Secondary Phone Number

Emergency Contact Information

Name

Primary Phone Number

Secondary Phone Number

Emergency Contact Information

Name

Primary Phone Number

Secondary Phone Number

Off Campus Travel

My student has permission to go off campus, after obtaining appropriate permission, with the following persons:

Parents

DAA Faculty

Own Vehicle

Relatives

Parents of other DAA Students

If yes please list parents that you are ok with your student traveling with.

Please specifiy if there are certain individuals with whom you DO NOT want your child to ride.

Verbal Permissions

Selecting "yes" for the following options will allow you to give verbal permission over the phone. I wish to be able to give verbal/phone permission for my student to be able to:

Use their car for educational, medical, work or family appointments

Obtaining permission for escused/arranged absences:

I give my full permission for all the above checked items and accept full responsibility for any accidents or injuries which might be incurred by my child while participating in any of the above checked items.

Signature Date

Medical Information

Student Name

Parent 1 Name

Parent 1 Phone Number

Parent 2 Name

Parent 2 Phone Number

Emergency Contact Name

Emergency Contact Phone Number

Health Insurance Company

Policy Number

Group Number

Primary Doctor Name

Primary Doctor Phone Number

Dentist Name

Dentist Phone Number

Allergies

Date of last Tetanus shot

Pertinent Medical Information

Does the student have prescribed medications?

Please list any prescription medications that this student is taking:

Tylenol

Topical Antibiotic Ointment

Ibuprofen

Benadryl

Please note that we will not allow students to self-administer medications

Consent to Treatment

I, the undersigned parent or guardian of the above minor, do hereby consent to any X-ray examination, immunization, anesthetic, medical or surgical diagnosis or treatment and hospital service that may be required to aid minor under the general or specific instruction of any physician the school or organization may call, whether such diagnosis or treatment is rendered at the office of said physician or at a licensed hospital. It is further understood that this consent is given in advance of any specific diagnosis or treatment which might be required and is given to authorize Dakota Adventist Academy or the physician to exercise their best judgment as to the requirements of such diagnosis or treatment. I hereby authorize any hospital physician, or other person who has attended or examined the minor to furnish the insurance service, or its representative, any and all information with respect to any illness, medical history, consultation, prescription or treatment, and copies of all hospital or medical records. A copy of this authorization shall be considered as effective and valid as the original. I, the undersigned parent or guardian of the above minor, hereby authorize the school nurse/dean/EMT of Dakota Adventist Academy to give over-the-counter medications in the event of minor illnesses and/or injuries such as headaches, colds, sore muscles, etc. All over-the-counter medication will be checked for compatibility with any prescription medication that your child may be taking. Please notify the school nurse of the medications your child is taking. If the condition persists, a medical evaluation will be obtained.

Signature

Date

Education Information

Student Name

List all schools attended fromt eh 8th grade to the current year. Include online or correspondence classes

8th Grade School

Phone Number

School Address

Report Card Submitted?

9th Grade School

Phone Number

School Address

Transcripts submitted?

10th Grade School

Phone Number

School Address

Transcripts submitted?

11th Grade School

Phone Number

School Address

Transcripts submitted?

Residence Information

Please check all that apply:

Dorm Student
Day Student
Host family needed for breaks

If needing host family for breaks, please answer the following questions.

Do you have any dietary restrictions?

Are you allergic to pets?

Is there additional information your host family will need?

References

Principal/Teacher Name

Phone Number

Address

Pastor/Coach Name

Phone

Address

Adult (non-family) Name

Phone

Address

Related Information

Forms