1 Background 2 Open-Ended Questions 3 Review 4 Complete If you have not already done so, please fill out the Interest Form first. If you are ready to continue the application process, please complete this questionnaire. You may navigate between the pages while filling out the form but cannot save answers to be submitted later. STUDENT INFORMATION Student First Name * Student Last Name * Student Birthday * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year2006200720082009201020112012201320142015201620172018 Has your family applied to Harlem Academy before? * No Yes SCHOOL INFORMATION Current School * Principal or Head School Address Current School City Current School State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Current School Zip Current School Telephone Has the applicant attended any other schools or educational programs in the last four years? * - Select -YesNo Previous School Dates Attended Previous School (If Applicable) Dates Attended PARENT/GUARDIAN INFORMATION Parent/Guardian 1 First Name * Parent/Guardian 1 Last Name * Parent/Guardian 1 Relationship with Applicant Parent/Guardian 1 Email * Parent/Guardian 1 Company Parent/Guardian 1 Occupation/Position Parent/Guardian 1 High School Parent/Guardian 1 College(s) Attended Parent/Guardian 1 Degrees Received Associate Bachelor Master Doctoral Other N/A Would you like to list an additional parent/guardian? * Yes No Parent/Guardian 2 First Name Parent/Guardian 2 Last Name Parent/Guardian 2 Email Parent/Guardian 2 Relationship with Applicant Parent/Guardian 2 Phone Is this person's address the same as the applicant's? Yes No Parent/Guardian 2 Address Parent/Guardian 2 City Parent/Guardian 2 State - None -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Parent/Guardian 2 Zip Parent/Guardian 2 Company Parent/Guardian 2 Occupation/Position Parent/Guardian 2 High School Parent/Guardian 2 College(s) Attended Parent/Guardian 2 Degrees Received Associate Bachelor Master Doctoral Other N/A FAMILY INFORMATION Select all that apply * Applicant lives with both parents Applicant lives with mother Applicant lives with father Mother deceased Father deceased Parents separated Parents divorced Mother remarried Father remarried N/A If the applicant does not live with one or both parents, please describe who the applicant lives with. Sibling 1 Name Sibling 2 Name Sibling 3 Name Sibling 4 Name Other Person Living with Applicant Leave this field blank
