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Student Information
Student Name*
First Middle Last
Preferred Name*
Gender*
Student Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone*
Year Enrolling
Applying for Grade*
Date of Birth*
MM
DD
YYYY
Upload Student Photo*
Place of Birth*
Citizenship*
Ethnic Background (Optional)
Ethnic Background Other
(Optional)
Current School
Current Grade
Does applicant currently receive special services to include: 504, IEP, RTI, etc.?*
- Yes
- No
Please detail services received.*
Is applicant in good behavioral and academic standing at current school?*
- Yes
- No
Principal/Head/Counselor
Grades Attended
Please list all grades attended, and enter n/a if not applicable.
Current School Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Current School Phone Number
Previous School
Previous School Grades Attended
Please enter all previous grades attended, or n/a if not applicable.
Reference*
First Last
(Other than relative)
Reference Phone Number*

Add Additional Child
Name (1)
First Middle Last
Gender (1)
Age (1)
Grade (1)
School (1)
Add Additional Child (2)
Name (2)
First Middle Last
Gender (2)
Age (2)
Grade (2)
Add Additional Child (3)
Name (3)
First Middle Last
Gender (3)
Age (3)
Grade (3)
School (3)
Add Additional Child (4)
Other Children
Please list names, genders, ages, grades, and schools for any additional children.
Do you have any relatives who have attended Clarksville Academy?*
Relative's Name
First Last
Relation to Applicant
Any additional information we should know about your child
How did you hear about Clarksville Academy?*
Authorization
I/We certify that all information provided above is complete, factually correct, and honestly presented, and that no substantive information has been omitted.
Application fee of $75.00 made payable to Clarksville Academy. You may pay through the online Marketplace or directly through the Business Office.
Person Responsible for payment*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Please Check:
Your signature authorizes Clarksville Academy to contact your child’s current school to obtain all academic records, behavioral records, and any additional information which will assist Clarksville Academy in it’s evaluation of your child.
Signature
Your signature authorizes Clarksville Academy to contact your child's current school to obtain teacher evaluations, recommendations, achievement test scores, attendance and behavior records, aptitude test results, transcripts and any additional information which will assist Clarksville Academy in its evaluation of your child.
Parent/Guardian Signature*
First Last
Date*

Clarksville Academy - Promoting Academic Excellence, Moral Integrity, Physical Growth, and Civic Responsibility

Application for Admission

Step 1 of 4

Student Information

To be completed by applicant if applicable

Family Information

Authorization

Signature