NOTRE DAME PREPARATORY 9701 E. Bell Rd., Scottsdale, AZ 85260 Phone: (480) 634-8200 Fax: (480) 634-8299 2011-2012 A P P L I C A T I O N F O R M (Please Print Clearly or Type)Entering Grade: ______________
STUDENT INFORMATION Student’s Primary Street Address
□ Multi-Racial (please specify)___________
Student’s Religion/ Denomination
□ Married □ Divorced □ Separated □ Single □ Widowed
Complete this Section if Parents are Divorced:
Father is remarried Mother is remarried
Student lives with: Mother Father Shared Guardian
If not joint custody, legal custody has been granted to: Mother Father
Legal documentation of birth parents regarding custody/visiting rights MUST be supplied. PARENT/GUARDIAN INFORMATION (In case of joint custody, please complete a separate application form for each custodial household.) Area Code & Home Phone Number Area Code & Home Phone Number Area Code & Cell Phone Number Area Code & Cell Phone Number Area Code & Work Phone Number Area Code & Work Phone Number Brothers & Sisters: Name Age Grade School Attending NDP Alumni (Yes or No) PARENT/GUARDIAN: What special circumstances that Notre Dame should be aware of have affected the applicant’s school performance, i.e., physical handicaps, illnesses, learning difficulties, frequent changes of home or school? ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ MEDICAL INFORMATION (Please print)
1.
Is the student taking any medications on a regular basis (i.e., insulin, Dilantin, Ritalin, etc.)?
If yes, please explain:____________________________________________________________________________________________________________ 2.
Has your student had any history of drug abuse?
If yes, please explain:____________________________________________________________________________________________________________ 3.
Does the student have any disabilities that Notre Dame should be aware (i.e., allergies, asthma, epilepsy, eye or ear problems, learning
disabilities), or are there any limitations on normal activities?
If yes, please explain:____________________________________________________________________________________________________________ ACADEMIC INFORMATION Schools student has attended in the past three years: School:_______________________________________________________________________________
Address:______________________________________________________________________________________________________________________
School:_______________________________________________________________________________
Address:______________________________________________________________________________________________________________________
Has the student ever repeated a grade, skipped a grade, or received accelerated instruction?
If yes, please explain circumstances:________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ A NON-REFUNDABLE APPLICATION FEE OF $50 is payable with this application.
For Office Use Only Interview Date:___________________________________________________ Assigned to:___________________________________________________ Application Complete:_____________________________________________ Acceptance Code:_______________________________________________
Notice: Benefits may vary by state or coverage may not be available in all states. The planis not available in Massachusetts, New Hampshire, New York, New Jersey, North Carolina,Oregon, Puerto Rico, Vermont and Washington. Table of Contents Table of Contents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10 Octobre 2007 DISTRIBUTION GRATUITE DE MOUSTIQUAIRES IMPREGNEES, D’ALBENDAZOLE ET DE VITAMINE A AUX ENFANTS DE MOINS DE CINQ ANS AU BENIN LE COUP D’ENVOI DE CETTE IMPORTANTE CAMPAGNE NATIONALE INTEGREE A ETE DONNE PAR LE CHEF DE L’ETAT BENINOIS, LE 10 OCTOBRE 2007 A OUIDAH La campagne nationale de distribution intégrée de moustiquaires imprégnées d’insectici