Student Application Thanks for your interest in attending Wellmont Academy. Please fill out the this application and we will notify you of the next steps. Step 1 of 6 16% Student InformationCurrent Grade Level*Kindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th GradeName* First Last Gender*MaleFemaleDOB* Place of Birth*Student ID Picture*Please choose a picture for the Student IDAccepted file types: jpg, jpeg, png.Address InformationCurrent Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Last address of student if different from above Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent/Guardian InformationFather's Name* First Last Father's EmployerFather's OccupationFather's Phone Number*Father's Email* Mother's Name* First Last Mother's EmployerMother's OccupationMother's Phone Number*Mother's Email* Spiritual InformationPastor or Small Group Church Leader's Name First Last Pastor/Leader's Phone NumberLength of Time Having Attended This ChurchParent's Statement of Faith*Briefly state your faith beliefs as specifically as possible. ReferencesReference 1*Please list the name of someone (non-family) who knows you and your child well. First Last Phone*Reference 2*Please list the name of someone (non-family) who knows you and your child well. First Last Phone* Emergency ContactsEmergency Contact 1*Person other than parent/legal guardian who is to be contacted in case of emergency. This person must be local and from a separate household than Emergency Contact 2. First Last Relationship*Phone*Emergency Contact 2*Person other than parent/legal guardian who is to be contacted in case of emergency. This person must be local and from a separate household than Emergency Contact 1. First Last Relationship*Phone*Medical InformationName of Insurance CompanyPolicy NumberPolicy Number OLD - DO NOT USEDoctor's Name* First Last Doctor's Phone Number*Recommended HospitalPlease list any medical concerns or psychiatric care we should be aware of. If none, please type "N/A".*Please list all student allergies. If none, please type "N/A".*Birth CertificateAccepted file types: jpg, gif, png, pdf.Please upload a copy of your child's birth certificate. *This is not required to complete this application. School InformationDesired School Entrance Date* Private or Flex Student Enrollment*I plan on signing up my child as a Privately enrolled student.I plan on signing up my child as a Flex student.Are you interested in signing your student up as a Private or Flex student with us? Privately enrolled students enjoy the following benefits: We keep track of all records, including grades and transcripts; year-end testing is included in your fee; private students are eligible to receive guidance counseling from our school guidance counselor; private students are eligible to receive a high school diploma from us upon graduation. By May 1st of this 2018, all diplomas moving forward are scheduled to be accredited diplomas. *The cost for Privately enrolled student services per year is $250. Flex Students enjoy the following benefits: parents keep track of all records, portfolios, and grades, including transcripts; parents are responsible for year-end testing; Flex students are eligible to receive a homeschool high school certificate upon graduation. *School Attendance History*This field displays data from applications prior to 5/28/2017 and is not on the current application.School Attendance History*School NameDate Started AttendingLength of Attendance in Years Please list all previous schools that your child has attended.Recent Evaluation Score, Standardized Assessment or Report Card Drop files here or Accepted file types: doc, docx, pdf. If available, please attach a copy of the student's most recent Evaluation, Test or Report Card. This helps us better serve your student. If you are unable to provide adequate documentation, your student will be required to complete an standardized assessment, administered by Wellmont's Testing Department, prior to enrollment, for an additional fee of $75.Parent Statement for Enrollment*Please give a brief but comprehensive statement of your reasons for applying to Wellmont for your child.How did you hear about Wellmont?*FriendRelativeWebsite SearchPinellas Parent Educators AssociationFacebookInstagramApplication Process Agreement*Upon receipt of this application, we will call you to schedule a family interview with a member of our staff. Acceptance to Wellmont is determined by our staff and is a matter of prayer. We will notify you of acceptance via email, beginning March 1st. Do you agree to this application process?YesNoDeposit Information*If your family is accepted to Wellmont, you will receive an email of acceptance, as well as a login to our online platform with directions for completing the rest of your registration forms. Upon receipt of these forms, a member of our staff will contact you to come to our office. There, you will complete your student's course placement and a payment agreement. At this time, your non-refundable $250 deposit will be due. You may pay by check, cash, money order, or Paypal (terms and conditions of Paypal apply). This deposit MUST be paid to hold your child's place. Do you understand and agree to these terms and conditions?I understand and agree to the above terms and conditions.I do not understandI do not agreeAgreement to abide by the rules of Wellmont Academy*As parents and prospective students, we agree to abide by the rules of Wellmont Academy. We understand that at any time, for any reason, Wellmont may choose to terminate our student's enrollment, making all payments and fees non-refundable if they see fit. We understand and agreeWe do not understandWe do not agreeNotice of RightsWellmont Academy of Tampa Bay, Inc. admits students of any race, color, national and ethnic origin to all the rights, privileges, programs, and activities generally accorded or made available to students at the school. It does not discriminate on the basis of race, color, national and ethnic origin in administration of it's educational policies, admissions policies, scholarship and load programs and athletic and other school-administered programs. UntitledFirst ChoiceSecond ChoiceThird ChoiceUntitledFirst ChoiceSecond ChoiceThird ChoiceUntitledFirst ChoiceSecond ChoiceThird ChoiceNameThis field is for validation purposes and should be left unchanged.
