Application Page 2
NEABC/Excelsior S.D.A. School
418 East 45th Street
Brooklyn, NY 11203
         Phone:: 718-693-5500  Fax: 718-940-4168


Parent Information - To be filled out by Parent:
Student Lives With (check all that apply):
 Father   Mother   Step-Father;   Step-Mother   Other   Father is Decesed   Mother is Decesed   Parents are Separated  *
Mother's Information Father's Information
Name: * Name: *
Address: * Address: *
State: * State: *
Zip Code: * Zip Code: *
Home Phone: * Home Phone: *
Cell Phone: * Cell Phone: *
Work Phone: Work Phone:
Employer: Employer:
Church/Denomination: Church/Denomination:
Please give names and birthdates of other children:
Child 1: Child 4:
Child 1 DOB: Child 4 DOB:
Child 2: Child 5:
Child 2 DOB: Child 5 DOB:
Child 3: Child 6:
Child 3 DOB: Child 6 DOB:
Has this student ever had a major illness, serious injury, or disability?
If yes, please explain and give the age at the time:
Has this student ever had psychological evaluation or treatment?
If yes please explain and provide documentation:
Has any member of the immediate family been seriously ill or disabled?
If yes please explain:
I will be applying for financial assistance through my church:
I need the appropriate forms:
Does this student have an unpaid school bill? *
If so, where?
How much is owed?
How did you first learn of NEABC/Excelsior SDA School?
List all schools since kindergarten:
Parent Commitment:
I agree to the conditions, regulations, and policies of NEABC/Excelsior SDA School as published in the school bulletin.  I have studied the finacial information in the current school bulletin and agree to assume the financial responsibility for the applicant. I understand that in addition to the down payment, which is due on registration day, there will be eight more installments charged to the account from October through May.  The balence due each month will be paid promptly.  I understand that this student's account with NEABC/Excelsior SDA School must be paid in full before a diploma or transcripts can be made available.
 Yes;  *       Date:*
Fields marked with an * are required.