Parkridge Private School Inc

Parkridge Private School Inc. 3605 Long Beach Boulevard, Suite 101, Long Beach, California 90807 (888)91-STUDY (562)424-5528 www.parkridgeschool.org

ENROLLMENT FORM

PLEASE PRINT AND COMPLETE ALL INFORMATION Date of Enrollment

STUDENT INFORMATION

Name First Middle Last Maiden

Address

City______State Zip Code Date of Birth

Home Phone # Cell Phone #

Work Phone #

Email Address:

PREVIOUS SCHOOL INFORMATION- Please list ALL schools you have attended. Use extra sheets if necessary. Include High Schools, Vocational Schools and Colleges.

LAST HIGH SCHOOL ATTENDED: Address

City______State Zip Code

Last Date Attended: (approximate month/year)

Grade Level(s) Completed: Credits Completed:

VOCATIONAL SCHOOL/COLLEGE ATTENDED:

Address City______State Zip Code

Last Date Attended: (approximate month/year)

Course(s) Completed: Units Completed:

Certificate(s) Received:

1 List the following: Certifications earned: (Example: CNA, CPR, Medical Assistant, Welding, Safety Training, Phlebotomy, etc.)

Licenses earned: (Example: Class A, B or C Driver’s License, Real Estate License, Contractors License, etc.)

Work Experience: Company name:

Position:

Duties:

Dates of Employment:

Company name: Position:

Duties:

Dates of Employment:

Company name:

Position:

Duties: Dates of Employment:

Company name:

Position:

Duties:

Dates of Employment: Company name:

Position:

Duties:

Dates of Employment: 2 Have you ever owned your own business? Yes No If yes, describe the following: Business type: Business license obtained: Yes No List duties: (Example: record keeping, accounts payable/receivable, payroll management, labor, etc.)

Have you ever been in the military? Yes No If yes, list the following: Branch: Rank: Years of Service:

Have you ever done volunteer work/service? Yes No (Example: Red Cross, Hospitals, Various Charities, Community Service, Habitat for Humanity, etc.) If yes, list the following: List organization(s): Duties performed: Total hours:

Have you ever been a member of a Youth/Faith Based Organization? (Example: Boy/Girl Scouts, YMCA, Camp Fire, etc.) If yes, list the following: List organization(s): Merit Badges or advancement earned:

Have you taken the GED? Yes No Passed? Yes No Have you taken the U.S. Citizenship test? Yes No Passed? Yes No

Have you ever received any recognition(s)? (Example: Dean’s List, Promotions, Employee of the Month, Honors, etc.) If yes, list the following: List recognition(s):

Check all that you have experience with or knowledge of:

___Computers Basic Intermediate Advanced ___Typing Basic Intermediate Advanced ___Children Care Basic Intermediate Advanced ___Sewing Basic Intermediate Advanced ___Cooking Basic Intermediate Advanced ___Auto Repair Basic Intermediate Advanced ___Home Repairs Basic Intermediate Advanced Art Basic Intermediate Advanced ___Musical Instrument Basic Intermediate Advanced (Instrument: ) ___Team Sport/Athlete Basic Intermediate Advanced (Sport/Type: ) ___Second Language Basic Intermediate Advanced (Language: ) Other

3 How did you hear about our program?

Recommended by:

Diploma Program Fee –(based on credits needed)- Payment must be paid in full at the time of enrollment in the form of cash, money order, Visa, or MasterCard. Please Note: If work is not completed within one year of start date, an additional fee may be required. You will receive two official transcripts upon completion of the program. Each additional transcript will be subject to a $5.00 fee. Signature:

Please print your name EXACTLY as you would like it to appear on your Diploma:

First Middle/Initial Last

(Office Use Only) Submitted: Resume Transcript (High School) Transcript (College) Certificates Government issued I.D. (copy) Letters of Verification