CTA Student Application Student First Name Last Name Date of Birth Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country Afghanistan Albania Algeria Andorra Antigua and Barbuda Argentina Armenia Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Central African Republic Chad Chile China Colombia Comoros Congo Cook Islands and Niue Costa Rica Côte d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France Gabon Gambia Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Yemen Zambia Zimbabwe Student Gender Male Female Ethnicity Last Grade Attended 5th 6th 7th 8th 9th 10th 11th 12th Home Phone - - Student's Cell # - - Email Male sponsor First Name Last Name Date of Birth Street Address (if different from above) Address Line 2 City State / Province / Region Postal / Zip Code Country Afghanistan Albania Algeria Andorra Antigua and Barbuda Argentina Armenia Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Central African Republic Chad Chile China Colombia Comoros Congo Cook Islands and Niue Costa Rica Côte d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France Gabon Gambia Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Yemen Zambia Zimbabwe Home Phone - - Work Phone - - Cell Phone - - May we call you at work? Yes No Relationship Father Grandfather Other If Other Female sponsor First Name Last Name Date of Birth Street Address (if different from above) Address Line 2 City State / Province / Region Postal / Zip Code Country Afghanistan Albania Algeria Andorra Antigua and Barbuda Argentina Armenia Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Central African Republic Chad Chile China Colombia Comoros Congo Cook Islands and Niue Costa Rica Côte d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France Gabon Gambia Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Yemen Zambia Zimbabwe Home Phone - - Work Phone - - Cell Phone - - May we call you at work? Yes No Relationship Mother Grandmother Other If Other (The following demographic information is required and is kept CONFIDENTIAL) Parent's Marital Status Married Divorced Unmarried Number of people in household Does this student have children? Yes No How many? Currently pregnant? Yes No Does this student have a parent that is currently incarcerated? Yes No In public school was your child eligible for free or reduced lunch? Yes No Has your child been diagnosed with any disabilities? Yes No Has your child ever received special educational services? Yes No Has your child ever received special educational services? Yes No Has this student ever had an IEP (under IDEA)? (if yes, a copy of the last IEP must be provided) Yes No Does this student have a 504 plan? (if yes, a copy must be provided) Yes No Emergency Contact Primary First Name Last Name Phone Number - - Relationship Secondary First Name Last Name Phone Number - - Relationship Additional First Name Last Name Phone Number - - Relationship Does the student currently receive the following benifits? (If yes to either of the below, the student is required by these agencies to attend a minimum of twenty inperson hours per week) Social security benefits Yes No V.A. benefits Yes No What is the reason for leaving the previous school? Why do you wish to attend Canterbury Technical Academy? Has the student applicant ever been suspended/expelled from school? (if yes, an explanation must be provided) Yes No Has the student ever been arrested? (if yes, an explanation must be provided) Yes No How did you learn about Canterbury Technical Academy? Referred / Recommended By Canterbury Technical Academy reserves the right to refuse admission to individuals based on, but not limited to the following conditions, the students: involvment with illegal substances, commitment of acts of violence, and/or convicted of a felony. Any person who contracts a contagious disease while attending Canterbury Technical Academy will not be allowed to attend classes until medical proof is provided that the student is no longer contagious. Canterbury Technical Academy may require participation of the student in various research programs, which can include academic, psychological, and other forms of testing. No name will be released with these test scores, but scores will be available to the parent and faculty of Canterbury Technical Academy to aid in the development of personalized program to enhance the educational benefits provided. There will be no additional charge for these services. I agree for my child to participate in all aspects of Canterbury Technical Academy, which may include: • Individual counseling provided by the school counselor, and/or (under supervision) a graduate student intern from one of the area universities • Testing and assessment for the purpose of providing insight and understanding of my child’s educational needs • My participation with my child in counseling or educational planning as requested by the staff of Canterbury Technical Academy. • Canterbury Technical Academy school uniform is maroon polos and khaki pants, knee length shorts or skirts. • Participation in photo or video productions from time to time that may be marketed to the general public. The signing of this application gives my permission and consent for the staff of Canterbury Technical Academy to have access to any of my student’s school records that may enable them to meet the needs of my child. I understand that all school records, counseling records and psychological testing will be held confidential. I understand that the counselors must make these records available only when a threat of serious harm to another person is present or when my child’s health or life is in immediate danger. I understand that it may become necessary for the school to consult with other agencies/institutions (i.e. Dept of Youth Services, DHR, Montgomery Public Schools, etc.). I give my permission for them to discuss my child’s treatment needs. By giving permission for my child to participate in all aspects in all aspects of Canterbury Technical Academy, I release Canterbury Academy, LLC. and any officer, agency, and/or institution it may consult with on behalf of my child from any and all liability that may be incurred in assisting my child in successfully completing his/her educational program. • Canterbury Technical Academy tuition is billed until your student is formally withdrawn or completes all course requirements (including any redo work), and all grading is completed. • Canterbury grading of all student work is reviewed by the teacher, and a student may be required to review answers with the teacher if questions arise as to the origin of the student’s work. • If a student turns in all coursework at one time grading could take several weeks. Tuition will have to be paid until all work is graded, no reassignments are due, and a credit slip is issued. • The financial sponsor of the student may be held liable for any damages incurred by the staff, faculty, student body, or Canterbury Academy, LLC., including but not limited to: cost to repair damages to physical property, medical costs, insurance fees, attorney’s fees, court costs, collection fees, and interest accrued for expenses related to actions or lack thereof of the student and/or the financial sponsor • I understand and agree to the addition of any and all fees charged for collection of unpaid tuition or other balances due including attorney's fees, court costs, and collection fees. This fee will be computed by and paid to Canterbury's authorized collections representative. • All students upon entrance to the Canterbury academic program may be required to complete the online placement test in reading and math. • By signing below, I acknowledge that I have received, read, and understand the Student Handbook and the code of conduct. I agree to abide by and follow the policies and procedures contained therein. I understand that the fee for enrollment is $200.00, and that the enrollment fees are billed yearly and under no circumstances will this fee be refunded. I also understand that this fee is separate from any tuition obligations or late fees incurred. By signing below, I acknowledge that I have received, read, and understand the school’s orientation booklet, tuition policies, and the school’s guidelines for behavior. I agree that I will support Canterbury Technical Academy and its efforts to enforce the regulations and policies contained in these documents. I have also been informed of Canterbury’s commitment to the Quality School guidelines and I agree to support all aspects of the educational program. I have also been informed of the emphasis that Canterbury Technical Academy places upon parent/legal guardian participation in the student’s education and agree to attend meetings with the staff to discuss the student’s progress and or diagnostic test results. Parents will be required to provide identification and sign a signature page upon enrollment. Submission of this form constitutes my signature. Today's date is: / /