Student Application

Student Information
Date
MM slash DD slash YYYY
Name
Gender
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Telephone
Phone
Student Email
Parent Email
Parent/Guardian Name
Telephone
Emergency Contact
Relationship
Tel:

Writing Sample
Please write a minimum of one paragraph (5 complete sentences)
You now have the opportunity for a fresh start in a new environment to successfully complete high school and obtain your high school diploma. Explaining in much detail, tell us here at Bronx Haven at least 3 unproductive behaviors or habits you will correct to ensure your graduation from BHHS.
**Please note you will be asked to sign and date at the bottom of this page as a means of holding you accountable to these changes in behaviors/habits if selected for admissions into Bronx Haven**
Name
Date
MM slash DD slash YYYY

Student Information