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Student Information
Date
MM slash DD slash YYYY
Name
Gender
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Telephone
Phone
Student Email
Parent Email
Parent/Guardian Name
Telephone
Emergency Contact
Relationship
Tel:
General School Information
Please list all high schools you attended.
School Name
Years Attended
School Name:
Years Attended
Total Credits Received
Regents Earned
MATH
SCIENCE
GLOBAL
US HIST
ENGLISH
Do you have an Individualized Education Plan (I.E.P.)?
Yes
No
Are you an ESL or ENL student?
Yes
No
Have you ever attended a GED program?
Yes
No
Have you ever attended a YABC?
Yes
No
At Bronx Haven High School, we expect and help all students to apply to college and/or other post-secondary programs. In order to best assist you with this process, including financial aid, please answer the following questions:
What is your first language?
English
Spanish
Do you speak another language?
Were you born in the United States?
Yes
No
In what country were you born?
Do you have any children?
Yes
No
How many?
Do you need assistance with childcare?
Yes
No
What’s your current childcare arrangement?
Health Issues
Do you have any allergies?
Yes
No
Do you take any prescription medications?
Yes
No
Do you have any health conditions we should be made aware of?
Yes
No
(e.g. heart conditions, asthma, breathing problems, diabetes, high blood pressure)
Do you have a primary care doctor?
Yes
No
Would you like assistance with additional health services?
Yes
No
General Employment History
Are you employed?
Yes
No
Work Shift
Day Shift
Night Shift
Overnight Shift
How long have you been employed?
Place of employment
Position
Have you ever volunteered or done community service?
Yes
No
Are you interested in participating in Eastsidehouse community events throughout the school year?
Yes
No
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