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320 10th Street N.E. Charlottesville, VA 22902
[email protected]
434-817-2371
Elementary and Middle School Application
Elementary and Middle School Application
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Applicant
Student Name
*
First
Middle
Last
Preferred First Name
Gender
*
- Select -
Female
Male
Age
*
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1
2
3
4
5
6
7
8
9
10
11
12
13
Date of Birth
*
Grade Applying for
*
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Kindergarten
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Sixth Grade
Seventh Grade
Eighth Grade
Home Address
*
Home Phone
*
Current School
*
Address of Current School
*
Telephone for Current School
*
Head of Current School
*
Previous Schools Attended / Dates of Attendance / Grade Levels
Applicants Primary Language / Other Language Spoken
Applicant’s Ethnicity (optional)
Does your student have any physical limitations or health conditions?
*
- Select -
Yes
No
If Yes, please explain physical limitations or health conditions
*
Family
Parent / Legal Guardian Name
*
First
Middle
Last
Address
*
Occupation
*
Employer
*
Home Phone
*
Work Phone
*
Cell Phone
*
Email
*
Parent / Legal Guardian Name
First
Middle
Last
Address
Occupation
Employer
Home Phone
Work Phone
Cell Phone
Email
Check all that apply:
*
parents together
parents separated
mother deceased
father deceased
parents divorced
father remarried
mother remarried
single parent
other
With whom does the student reside?
Who has legal custody of the student?
Name of step-parent(s) if applicable:
Other children in the family (Name, Year of Birth, School):
Any unusual family situation:
Name of person financially responsible for tuition and fees:
How did you hear about Charlottesville Day School:
Any other information you would like us to have about your student:
Check here if you wish to have financial assistance information emailed to you.
Application Fee
*
Application Fee
$0.00
Credit Card
*
American Express
Discover
MasterCard
Visa
Card Number
Month
01
02
03
04
05
06
07
08
09
10
11
12
Year
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
Expiration Date
Security Code
Cardholder Name
Comments
This field is for validation purposes and should be left unchanged.
