Registration Application
Registration Application
P O R T L E D G E
S C H O O L
TRANSCRIPT RELEASE FORM To be completed by Parent or Guardian. Dear Parents, In order to develop a clearer picture of your child’s record of achievement and academic and personal potential, we need your permission to request reports from his or her present school. Please complete the information below which will authorize the release of appropriate records to Portledge School. After you have signed this authorization form, please return it to our Admissions Office. Thank you.
Portledge School Admissions
Dear Principal or Head, As the parent/guardian of ____________________________________________, I hereby authorize the release of all appropriate information concerning his or her academic, personal, and medical records to Portledge School. I understand that this information will be used in connection with our application to Portledge School and will be held in strict confidence. ________________________________________________________________ Parent or Guardian Signature Date
355 Duck Pond Road Locust Valley, NY 11560 Telephone (516) 750-3203 or (516) 750-3202 Fax (516) 671-2039 www.portledge.org
Portledge School admits students without regard to race, color, religion, gender, sexual orientation, or national and ethnic origin to all rights, privileges, programs and activities generally accorded or made available to students at the school. It does not discriminate on the basis or race, color, religion, gender, sexual orientation, national and ethnic origin in the administration of its educational policies, admissions policies, and athletic and other schooladministered programs.
355 Duck Pond Road Locust Valley, NY 11560 (516) 750-3203 or (516) 750-3202 www.portledge.org
REGISTRATION FOR APPLICATION Please Print or Type. Submit as soon as possible; this form must be received in order to open an applicant file. Please include $75 non-refundable application fee. International Application fee: $250
❏ Male ❏ Female
Preferred Name or Nickname _________________________
Applicant’s Name _________________________________
Date of Birth ______________________________________
Address _________________________________________
Birthplace ________________________________________
City ____________________________________________
Country of Citizenship _______________________________
State ______________________ Zip__________________
Present Grade _________ Applicant for Grade ___________
Telephone _______________________________________
Entering September of (year) _________________________
Soc. Sec. No. ______________________________________
School District ______________________ District #_______
Student lives with: ❏ Parents
❏ Parent A
❏ Parent B
Only
❏ Guardian
❏ Other ______________________
Only
PARENT INFORMATION
Parent A
Parent B
❏ Mr. ❏ Ms. ❏ Mrs. ❏ Dr.
❏ Mr. ❏ Ms. ❏ Mrs. ❏ Dr.
Name___________________________________________
Name ____________________________________________
Address _________________________________________ (if different from above)
Address __________________________________________ (if different from above)
City ____________________________________________
City _____________________________________________
State ________________________Zip_________________
State ________________________Zip__________________
Telephone _______________________________________
Telephone ________________________________________
Email ___________________________________________
Email ____________________________________________
Secondary School Attended _________________________
Secondary School Attended __________________________
College(s) Attended _______________________________
College(s) Attended ________________________________
Occupation ______________________________________
Occupation _______________________________________
Employer ________________________________________
Employer _________________________________________
Business Address __________________________________
Business Address ___________________________________
City ____________________________________________
City _____________________________________________
State ________________________Zip_________________
State ________________________Zip__________________
Business Phone____________________________________
Business Phone ____________________________________
Stepparent (if applicable)___________________________
Stepparent (if applicable)_____________________________
1. Previous Schooling: For Lower School applicants, it is the school’s policy to send for reports from the student’s present school. Although parents are responsible for requesting reports for Middle and Upper School applicants, Portledge may contact the student’s present school for clarification or further information. Please list the student’s present school. Present School_____________________________________________ Current Grade_________________________________ Name of Principal / School Head_______________________________ Title________________________________________ Name of Guidance Counselor / Homeroom Teacher_____________________________________Position_________________ School Address_____________________________________________ City ________________________________________ State_________________________________Zip__________________Telephone ___________________________________ Previous School_____________________________________________Grade Completed _____Year ____________________ 2. Brothers and Sisters: NAME
BIRTHDATE
PRESENT GRADE
PRESENT SCHOOL
1. ____________________________________________________________________________________________________ 2. ____________________________________________________________________________________________________ 3. ____________________________________________________________________________________________________ 4. ____________________________________________________________________________________________________ 3. If any relative is, or has been a student at Portledge, give name, relationship to applicant, and graduating class. NAME
RELATIONSHIP
GRADUATING CLASS
1. ____________________________________________________________________________________________________ 2. ____________________________________________________________________________________________________ 3. ____________________________________________________________________________________________________ 4. ____________________________________________________________________________________________________ 4. How did you hear about Portledge School? _____________________________________________________________ 5. Will you be a candidate for financial aid?
Yes
No
6. Would you be interested in being a candidate for our Early Commitment Program?
Yes
No
The Early Commitment program is designed for students who have decided that Portledge is their first choice school. If accepted under Early Commitment, students have two weeks within receipt of contract to make an enrollment deposit and guarantee their space for the upcoming year.
Application Deadline: December 18
Notification Deadline: January 19
In consideration of the undertaking by the Office of Admissions of Portledge School to process this candidate’s Admission Application and related forms the undersigned agrees that the information furnished on the Application for Admission form, together with all information and materials of any kind received by the Admissions Office from any source, or prepared by anyone at its request, shall be completely confidential and shall not be disclosed to anyone, including the candidate and the candidate’s family, except that the Director of Admissions may, for official purposes at his or her discretion, disclose any part thereof to such person or persons as he or she deems advisable. Parent’s Signature (or Guardian’s Signature) ____________________________________________ Date __________________ Please be certain you have enclosed your non-refundable application fee.
P O R T L E D G E
S C H O O L
TRANSCRIPT RELEASE FORM To be completed by Parent or Guardian. Dear Parents, In order to develop a clearer picture of your child’s record of achievement and academic and personal potential, we need your permission to request reports from his or her present school. Please complete the information below which will authorize the release of appropriate records to Portledge School. After you have signed this authorization form, please return it to our Admissions Office. Thank you.
Portledge School Admissions
Dear Principal or Head, As the parent/guardian of ____________________________________________, I hereby authorize the release of all appropriate information concerning his or her academic, personal, and medical records to Portledge School. I understand that this information will be used in connection with our application to Portledge School and will be held in strict confidence. ________________________________________________________________ Parent or Guardian Signature Date
355 Duck Pond Road Locust Valley, NY 11560 Telephone (516) 750-3203 or (516) 750-3202 Fax (516) 671-2039 www.portledge.org
Portledge School admits students without regard to race, color, religion, gender, sexual orientation, or national and ethnic origin to all rights, privileges, programs and activities generally accorded or made available to students at the school. It does not discriminate on the basis or race, color, religion, gender, sexual orientation, national and ethnic origin in the administration of its educational policies, admissions policies, and athletic and other schooladministered programs.
355 Duck Pond Road Locust Valley, NY 11560 (516) 750-3203 or (516) 750-3202 www.portledge.org
REGISTRATION FOR APPLICATION Please Print or Type. Submit as soon as possible; this form must be received in order to open an applicant file. Please include $75 non-refundable application fee. International Application fee: $250
❏ Male ❏ Female
Preferred Name or Nickname _________________________
Applicant’s Name _________________________________
Date of Birth ______________________________________
Address _________________________________________
Birthplace ________________________________________
City ____________________________________________
Country of Citizenship _______________________________
State ______________________ Zip__________________
Present Grade _________ Applicant for Grade ___________
Telephone _______________________________________
Entering September of (year) _________________________
Soc. Sec. No. ______________________________________
School District ______________________ District #_______
Student lives with: ❏ Parents
❏ Parent A
❏ Parent B
Only
❏ Guardian
❏ Other ______________________
Only
PARENT INFORMATION
Parent A
Parent B
❏ Mr. ❏ Ms. ❏ Mrs. ❏ Dr.
❏ Mr. ❏ Ms. ❏ Mrs. ❏ Dr.
Name___________________________________________
Name ____________________________________________
Address _________________________________________ (if different from above)
Address __________________________________________ (if different from above)
City ____________________________________________
City _____________________________________________
State ________________________Zip_________________
State ________________________Zip__________________
Telephone _______________________________________
Telephone ________________________________________
Email ___________________________________________
Email ____________________________________________
Secondary School Attended _________________________
Secondary School Attended __________________________
College(s) Attended _______________________________
College(s) Attended ________________________________
Occupation ______________________________________
Occupation _______________________________________
Employer ________________________________________
Employer _________________________________________
Business Address __________________________________
Business Address ___________________________________
City ____________________________________________
City _____________________________________________
State ________________________Zip_________________
State ________________________Zip__________________
Business Phone____________________________________
Business Phone ____________________________________
Stepparent (if applicable)___________________________
Stepparent (if applicable)_____________________________
1. Previous Schooling: For Lower School applicants, it is the school’s policy to send for reports from the student’s present school. Although parents are responsible for requesting reports for Middle and Upper School applicants, Portledge may contact the student’s present school for clarification or further information. Please list the student’s present school. Present School_____________________________________________ Current Grade_________________________________ Name of Principal / School Head_______________________________ Title________________________________________ Name of Guidance Counselor / Homeroom Teacher_____________________________________Position_________________ School Address_____________________________________________ City ________________________________________ State_________________________________Zip__________________Telephone ___________________________________ Previous School_____________________________________________Grade Completed _____Year ____________________ 2. Brothers and Sisters: NAME
BIRTHDATE
PRESENT GRADE
PRESENT SCHOOL
1. ____________________________________________________________________________________________________ 2. ____________________________________________________________________________________________________ 3. ____________________________________________________________________________________________________ 4. ____________________________________________________________________________________________________ 3. If any relative is, or has been a student at Portledge, give name, relationship to applicant, and graduating class. NAME
RELATIONSHIP
GRADUATING CLASS
1. ____________________________________________________________________________________________________ 2. ____________________________________________________________________________________________________ 3. ____________________________________________________________________________________________________ 4. ____________________________________________________________________________________________________ 4. How did you hear about Portledge School? _____________________________________________________________ 5. Will you be a candidate for financial aid?
Yes
No
6. Would you be interested in being a candidate for our Early Commitment Program?
Yes
No
The Early Commitment program is designed for students who have decided that Portledge is their first choice school. If accepted under Early Commitment, students have two weeks within receipt of contract to make an enrollment deposit and guarantee their space for the upcoming year.
Application Deadline: December 18
Notification Deadline: January 19
In consideration of the undertaking by the Office of Admissions of Portledge School to process this candidate’s Admission Application and related forms the undersigned agrees that the information furnished on the Application for Admission form, together with all information and materials of any kind received by the Admissions Office from any source, or prepared by anyone at its request, shall be completely confidential and shall not be disclosed to anyone, including the candidate and the candidate’s family, except that the Director of Admissions may, for official purposes at his or her discretion, disclose any part thereof to such person or persons as he or she deems advisable. Parent’s Signature (or Guardian’s Signature) ____________________________________________ Date __________________ Please be certain you have enclosed your non-refundable application fee.
