Wentworth Private Military Academy & Junior College Online Application

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Student Profile

. COMPLETE LA FORMA EN ESPAÑOL .

Please complete this form if your are applying for admission to Wentworth. If you would simply like more information on the school, click here.

TERM APPLYING FOR:

High School Scholars Program, Academic Year 2008-2009

Accelerated Scholars Program, Academic Year 2008-2009

Military College (SROTC), Academic Year 2008-2009

Military College (not SROTC), Academic Year 2008-2009

What Grade Are You Applying For?

STUDENT INFORMATION:

Name of Applicant:*

(Last)	(First)	(Middle)
Date of Birth:*	/ /	Age:

Preferred Nickname:

Gender:*	Male Female

Address:*
	(Street Address)


	(City, State & ZIP)

Phone:*


Citizenship:

Country of Birth:

Dual Citizenship?	Yes No

International Students Only* Are you a U.S. Citizen but reside primarily outside the U.S? Yes No

Are you a citizen of another country currently living in the U.S.? Yes No

Which country is your primary residence?

FAMILY INFORMATION:

Parent/Guardian 1

Relationship to applicant:* Name*:

Home Address (if other than cadet):*

E-mail address:*

Home Phone:* Cell Phone:*

Fax:

Profession: Employed by:

Business Phone:*

Parent/Guardian 2

Relationship to applicant: Name:

Home Address (if other than cadet):

E-mail address:

Home Phone: Cell Phone:

Fax:

Profession: Employed by:

Business Phone:

PART 4: APPLICANT DISCLOSURES

*Has the applicant ever received counseling or assistance for emotional, physical, medical, or behavioral problems that may affect the ability to live away from home in a rigorous, highly structured and competitive college preparatory environment, including but not limited to the following (check all that apply, and please explain below):

NONE OF THESE APPLY
Drug or alcohol use; cigarettes or other tobacco products; or misuse of over-the-counter medications
Depression or low self-esteem
Suicide
Eating or other compulsive disorders
Food allergy (peanut, for example?)
Confrontational or violent behavior; problems with authority
Self destructive behavior
ADD / ADHD
Oppositional Defiant Disorder (ODD)
Any other disorder, physical limitation or behavior? Possible examples include, but are not limited to: bi-polar disorder, autism, anxiety attacks, epilepsy, hallucinations, diabetes, phobias, and bed wetting.

*If you checked any of the options above please explain further:

*If your child is taking medication, please explain further:

*Does the applicant have any record of involvement with law enforcement or civil authorities – either current or in the past, adult or juvenile – and is the applicant now or has at any time in the past been on probation? (The following is included: any arrest, charge, citation or detention for any violation, even those now expunged and/or the existence of a SIS).

YES NO

Please Explain:

*I have read and understand the Statements of Understanding

The Student Profile is the first step in applying to Wentworth. Click here to to learn more!