Student Information
Copy of Birth Certificate and up-to-date Immunization Records must be on file before a child can attend/enroll in school.
Date January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901
School Year
Student's Name
Half Day K
Full Day K
Entering Grade
Male
Female
Yes
No
Age
DOB January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901
Place of Birth
Student's Email
, AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Student's Home Phone( ) -
Student's Cell Phone( ) -
If yes, where?
Name of Church, City, State
Student's Church Membership
Local church or local affiliation, denomination
Student’s Health Concerns
Takes medication regularly, wears glasses or contacts, hearing problems, allergies, diabetic, etc.
If yes, please explain
Student’s Last School Attended
If yes, please submit a copy to the Registrar.
If yes, please submit a written explanation
Physician
Primary Care Provider’s Name, Phone Number
Parent Information
Parent/Guardian Full Name
Relationship to student
Occupation
Employer
Business Phone( ) -
Cell Phone( ) -
Home Phone( ) -
Email
Church Affiliation
Denomination
If parents are separated/divorced, who has legal custody?
With whom does this student live with?
N/A
Copies of official custody and/or No Contact paperwork must be on file.
Name
If parents cannot be reached, whom may we call in case of an emergency? Parents will always be called first
Phone( ) -
Student is authorized to ride in a car driven by the following driver(s):
Non-Refundable Registration Fee - I understand the Pre-Registration and/or Registration Fee is nonrefundable and non-transferable.
Library Lending - I the parent agree that if any library books assigned to my child become damaged, misused beyond normal wear and tear, or are lost, I will pay the school for the replacement cost of the book.
Due Process - Rules and policies announced by the administration during the school year will take precedence over statements previously printed in the handbook.
School Directory - I understand that my name, address, and phone number will be put into a school directory. My child’s name and grade will also be included. I understand that the school directory is for current school families and staff only. I agree not to distribute this information to others.
Photo/Video Release - I hereby grant RVAA and its employees, agents and assigns, the right to photograph my dependent and use the photo, derivatives, and/or other digital reproductions of him/her or other reproductions of his/her physical likeness for publication purposes, whether electronic, print, digital or electronic publishing via the internet. Furthermore, I assign the rights for any recording, be it audio and/or visual, to be used in the same manner as the aforementioned photographs. Example: Website, PR, Yearbook, wall posters, etc.
Disclaimer - Rogue Valley Adventist Academy reserves the right to withdraw acceptance or dismiss the applicant from school in the event that incomplete or inaccurate information is provide. The application information is confidential and is intended for the school’s purposes only. This form is an application for admission only.
Parent Contract
We (I) are in agreement with the objectives, standards, and policies of Rogue Valley Adventist Academy. We (I) will support the school and staff, and upon acceptance I accept full financial responsibility for the above student. We (I) affirm that the information provided in this application is true to the best of our (my) knowledge.
Parent/Guardian Signature
Please enter your name is lieu of a signature
Student Contract
I have read the objectives, and policies of this school. If I am accepted by the school, I will endeavor at all times to uphold the Christian standards of the school and to respect the staff and the rules.
Student Signature
What characteristics of RVAA interest your family, and why do you feel that our school is a good match for your child?
RVAA is dedicated to nurturing and encouraging students’ intellectual, artistic, social, physical, and spiritual abilities. What are your child’s strengths in these areas?
Please describe any learning disabilities our child may have and any accommodations they may need.
Rogue Valley Adventist Academy does not discriminate on the basis of race, color, religion, national or ethnic origin, gender, or handicap in the administration of its educational program, admission policies, and other school-administered programs.
Please submit this application with the non-refundable registration fee to:
Rogue Valley Adventist AcademyAdmissions/Registrar3675 S. Stage RoadMedford, OR 97501
