Epiphany Lutheran Church

Wittenberg Learning Center                                                                  

APPLICATION

13495 Keytone Road

Dale City, VA  22193

Phone: 703-730-1735

I am applying to the Wittenberg Learning Center for my child for academic year 2007-2008.  I am aware that it would be helpful for the center to have transcripts sent from any school my child has attended in the past three years.  I understand that in addition to the donation to Epiphany Lutheran Church, I must enroll in and pay tuition to Boston School, and purchase books and school supplies for my child.

APPLICANT INFORMATION

Student’s Name

Last_____________________________    

First_____________________________

Middle______

Nickname_______________________

Male/Female__________

Address

Street________________________________________________________________________________

City_______________________________________ State_______________

Zip___________________

Phone_____________________________

Date of Birth________________________    Age in Years________

Place of Birth_______________________________________

Citizenship_____________________________

Religious Affiliation___________________________

Home Congregation___________________________

SCHOOLS

Present School__________________________________________________

Present Grade______________

Address of Present School

            Street________________________________________________________________________________

City_______________________________________

State___________________ Zip_______________

Phone______________________________________Principal________________________________________

Dates of Attendance_________________________________________________________________________

Former Schools (list in order, beginning with the most recent)

            School                                   Address                                               Dates Attended

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

CUSTODIAL PARENT INFORMATION

FATHER

Name

Last_______________________________________

First______________________________________

Address

            Street________________________________________________________________________________

City__________________________________________

State________________ Zip_______________

Home Phone_______________________________

Work Phone_____________________________________

Cell Phone___________________________

E-mail Address________________________________________

Religious Affiliation___________________________

Home Congregation___________________________

Employer__________________________________

Position/Title___________________________________

MOTHER

Name

Last_______________________________________

First______________________________________

Address

            Street________________________________________________________________________________

City__________________________________________

State________________ Zip_______________

Home Phone_______________________________

Work Phone_____________________________________

Cell Phone___________________________

E-mail Address________________________________________

Religious Affiliation___________________________

Home Congregation___________________________

Employer__________________________________

Position/Title___________________________________

Applicant lives with:                 

Mother_______    Father_______    Other_______

If other, please provide

name and address____________________________________________________

_____________________________________________________________________________________________

Who should receive correspondence? ________________________________________________________

SIBLING INFORMATION

Name                     Date of Birth              School                             Grade

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

OTHER INFORMATION

How did you learn about Wittenberg Learning Center?

_____________________________________________________________________________________________

Please list applicant’s top three extracurricular interests:

1.      __________________________________________________________________________________________

2.      __________________________________________________________________________________________

3.      __________________________________________________________________________________________

Has the applicant any history of unusual physical or emotional conditions or learning difficulties, which require professional attention or which might require special attention?                                                                   Yes                        No

Has the student had any educational or psychological testing done in the past three years?                                                

                                                                                    Yes                        No

If yes, will you provide Wittenberg Learning Center with a copy of the test results and/or recommendations?    

                                                                                     Yes                       No

Has the applicant ever been dismissed, suspended, or had any disciplinary action taken at any school they have attended?                                                                     Yes                        No

If yes, please explain, and give the date and name of school. 

_____________________________________________________________________________________________

Why do you want your child to attend the Wittenberg Learning Center? _____________________________________________________________________________________________

_____________________________________________________________________________________________

We welcome any additional parent comments that would support your child’s record.

SIGNATURE AND DONATION

Person Responsible for donations to Epiphany Lutheran Church:

________________________________

Address:

            Street________________________________________________________________________________

City______________________________________ State_________________

Zip_________________

Phone_____________________________

I give Wittenberg Learning Center permission to contact the applicant’s current school for

additional information, if necessary.

 Parent/Guardian Signature _______________________________________

Date____________________

Send completed form with $50 donation.  Make check payable to Epiphany Lutheran Church.

Epiphany Lutheran Church

Wittenberg Learning Center

13495 Keytone Road

Dale City, VA  22193

Epiphany Lutheran Church

Wittenberg Learning Center

13495 Keytone Road

Dale City, VA  22193

Phone: 703-730-1735

TRANSCRIPT RELEASE FORM

Student’s name_________________________________________

Date of Birth____________________________________________

TO THE PARENT OR GUARDIAN:

Please sign this form and send it to your child’s former school.

I give permission for __________________________________to my child’s

                                                (Name of school)

records to the Wittenberg Learning Center.

Signature of parent/guardian__________________________________

Date__________________

TO THE REGISTRAR

This student has applied for services at Wittenberg Learning Center.  Please send this student’s transcript to the above address.                       Thank you.