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Student Information |
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Name of Student |
:
(family)
:
(first)
:
(middle)
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Date of Birth |
:
(dd/mm/yy)
(age)
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Male
Female |
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Most proficient language |
:
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Other language spoken |
:
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Nationality |
:
(student)
:
(father)
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Passport Number |
:
(student)
:
(father)
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Passport Expiration Date |
:
(student)
:
(father)
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Stay Permit Type |
KITAS
Dinas
Other (student)
KITAS
Dinas
Other (father) |
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Stay Permit Number |
:
(student)
:
(father)
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Stay Permit Expiration Date |
:
(student)
:
(father)
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Applying for |
K-6
7-8
9-12 |
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Boarding Status |
Non-Boarding
Boarding |
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Name of sibling(s) already enrolled |
:
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Family Information |
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Name of Father |
:
(family)
:
(first)
:
(middle)
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Name of Mother |
:
(family)
:
(first)
:
(middle)
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Address |
:
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Phones |
:
(home phone)
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:
(home fax)
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:
(HP father)
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:
(HP mother)
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Parent's Email Address |
:
(E-mail father)
:
(E-mail mother)
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Religion |
:
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Employment Information |
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Company/Sending Agency |
:
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Father’s Job Title |
:
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Office Address |
:
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Office Phone |
:
Ext
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Office Fax |
:
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Email Address |
:
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Emergency Contact/Temporary
Guardian |
We give authority to the following person(s) to
make all decisions or to take charge of our child in an
emergency or urgent situation when we cannot be contacted: |
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Name |
:
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Address |
:
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Home Phone |
:
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HP |
:
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Email |
:
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Academic Information |
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Name of Previous School |
:
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Current or Most Recently Finished Grade |
:
check if completed
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School Address |
:
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Office Phone |
:
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School Fax |
:
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Email Address |
:
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Has your child ever been expelled or
suspended from school?
Yes
No
If yes, please explain
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Does your child have learning
disabilities/handicaps*?
Yes
No
If yes, please explain
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Has your child ever received Special
Education services*?
Yes
No
If yes, please explain
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Has your child ever received counseling for
emotional/mental problems*?
Yes
No
If yes, please explain
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Has your child ever used non-medical drugs
or alcohol?
Yes
No
If yes, please explain
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*IMPORTANT: Please attach all formal testing
or medical reports or documents, as well as any
explanation that does not fit in the space above. |
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Health Information |
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Height
Weight
Posture
Hearing
Vision
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Does your child have insurance coverage?
Yes
No
Name of insurance company:
Coverage:
Medical
Dental
Life |
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Does your child require medication on a
regular basis?
Yes
No
If yes, what type & dosage:
[For prescription medications, please attach a
doctor’s prescription or letter.] |
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Are there hereditary health problems in other family members we
should be aware of?
Yes
No If yes, please explain
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Has your child experienced any of
the following diseases? Please circle Yes or No. If Yes, please write the date
of occurrence. |
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Measles |
Yes No
date
(dd/mm/yy) |
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Mumps |
Yes No
date
(dd/mm/yy)
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Rubella |
Yes No
date
(dd/mm/yy)
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Hepatitis A |
Yes No
date
(dd/mm/yy)
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Hepatitis B |
Yes No
date
(dd/mm/yy)
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Chickenpox |
Yes No
date
(dd/mm/yy)
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Cholera |
Yes No
date
(dd/mm/yy)
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Scarlet Fever |
Yes No
date
(dd/mm/yy)
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Typhoid Fever |
Yes No
date
(dd/mm/yy)
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Polio |
Yes No
date
(dd/mm/yy)
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Whooping Cough |
Yes No
date
(dd/mm/yy)
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Rheumatic Fever |
Yes No
date
(dd/mm/yy)
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Others |
Yes No
date
(dd/mm/yy)
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Does your
child suffer from any of the following conditions? Please check if Yes or No.
If Yes, please explain: |
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Asthma |
Yes No
explain
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Diabetes |
Yes No
explain
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Epilepsy |
Yes No
explain
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Heart Abnormality |
Yes No
explain
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Physical Handicaps |
Yes No
explain
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Speech Defect |
Yes No
explain
|
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Allergies |
Yes No
explain
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Others |
Yes No
explain
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Note: If your child
suffers from any condition that would affect normal participation in classes
and school activities, including physical education, please attach a recent
doctor’s report with clear limitations explaining permissible and
non-permissible activities. |
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Please list the dates for each
immunization that your child has received for the diseases listed below.
(date/month/year) |
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Measles |
Date 1
Date 2
Date 3
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Mumps |
Date 1
Date 2
Date 3
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Rubella |
Date 1
Date 2
Date 3
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DPT/DT |
Date 1
Date 2
Date 3
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Oral Polio |
Date 1
Date 2
Date 3
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Thypoid |
Date 1
Date 2
Date 3
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BCG |
Date 1
Date 2
Date 3
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Smallpox |
Date 1
Date 2
Date 3
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Hepatitis A |
Date 1
Date 2
Date 3
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Hepatitis B |
Date 1
Date 2
Date 3
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Mantoux (TB) |
Date 1
Date 2
Date 3
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X-ray (TB) |
Date 1
Date 2
Date 3
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Tetanus |
Date 1
Date 2
Date 3
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Others |
Date 1
Date 2
Date 3
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Please answer
the following questions in case your child contracts a severe illness or has
an accident, and we cannot contact you or your selected guardian: |
1. If immediate
hospitalization is required, may we use a Salatiga hospital until your child
can safely be
transferred to the hospital of your choice?
Yes No |
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2. What is the hospital of your
choice? |
:
Phone
|
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3. Who is the doctor of your
choice? |
:
Phone
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4. In case of illness or
injury that is treatable here, may the school nurse treat it?
Yes No |
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5. If needed, may we use a
staff-approved local (Salatiga) doctor at the nurse’s direction?
Yes No |
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If No, which doctor in Salatiga
do you suggest? If the same doctor as in #3, please check here:
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If another, write the name here: |
:
Phone
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Non-Discrimination Policy |
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Mountainview does not discriminate on the basis of gender, race, color, or ethnic origin in admissions or adminstration of its policies and programs.
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Authorization |
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Parent Initials |
We hereby grant authority to the
school nurse or school staff member involved to have this child medically
treated as necessary in an emergency, and as close as possible to our
instructions in any non-emergency situation. The school is released from
liability in all medical treatment. All medical expenses will be borne by us
and/or our insurance company. |
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Parent Initials |
We authorize the school nurse
and/or administration to obtain professional medical testing if it is deemed
advisable for health reasons or for suspicion of substance abuse. This is left
up to the discretion of the school nurse and/or administration. If urgent
circumstances require this testing without advance parental notification, it
will be at the school’s expense. All other expenses will
be borne by us and/or our insurance company. |
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Parent Initials |
We hereby grant permission for
this child to participate in all regular
teacher/parent-supervised school activities and outings. We understand that
this release form is in lieu of individual release forms being used throughout
the school year. We release the school from liability when this child is
participating in such activities. |
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Parent Initials |
We understand that Mountainview
is a Christian school and that participation in Christian studies and
activities is required of all students. We hereby grant permission for our
child to participate in such studies and activities. |
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We certify that all of the
information in this document is true and complete. |
:
(typed OK) Date
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Warning of Global Obligations |
Mountainview has a responsibility
to maintain the legal status of this school in the eyes of the
government of Indonesia. Thus, Mountainview retains the right to acquire any
documents necessary
to verify the applicant’s residency, parental or citizenship status. The
residency document KITAS is
the main legal document needed by this school. Once the expiration date
arrives and the new KITAS
is being processed, a letter from the parents’ sponsoring agency or company
must be sent to the
Registrar’s office stating that the KITAS is in process. The copy of the new
KITAS should be sent to
the Registrar’s office within 30 days after the Registrar receives the letter.
Failure to comply with the
government’s regulation for our school could result in the student’s dismissal
from Mountainview
International Christian School. |
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Admission Requirements |
Please be aware that an
application will not be processed for admission until this completed
application and all supporting documents have been received by the
Registrar’s Office. The following documents must be submitted with this
completed application:
- Photocopy of Passport (cover page, picture page, vital information page,
expiration date) of both student and father. Please provide 2 copies of
each for Boarding applicants.
- Photocopy of the Limited Stay Permit (KITAS) for both student and father.
Please provide 2 copies of each for Boarding applicants. If the KITAS is
in process, a letter from the sponsoring agency or company is required, and
the copy of new KITAS must be sent within 30 days of enrollment.
- At least a year of previous educational records (transcript or last report
card) from the school most recently attended. Transcripts for all completed
secondary grades (not just report cards, and not just the most recent year)
are required for all students applying for grades 9-12. Education records from
non-English speaking schools must be officially translated into English.
- Five (5) current photographs of the student (3 cm x 4 cm)
- For Indonesian citizens, in reference to the Joint Decree of the Minister of
Foreign Affairs, Education and Culture, and Finance (1975), a letter of
dispensation from Depdiknas in Jakarta.
- For boarding applicants, a completed Boarding Application Form.
An
application is complete when the Registrar receives all of the above-mentioned
documents. All admissions requirements must be met prior to testing and
acceptance into Mountainview.
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