New Student Application for Pillow Academy

New Student
Application for Admission
2012 - 2013
Attention: Karen W. Makamson
Pillow Academy
69601 Highway 82 West
Greenwood, MS 38930
Express Registration: To qualify for this type of Registration admission application and form of payment (check, post-dated checks, or voided checks) must
be completed and returned by January 31, 2012. Please direct your information to Karen W. Makamson. Please print or type all information.
Student #1s Full Name ___________________________________________________ Preferred Name____________________________

Last
First
Middle
Date of Birth _________________________ Social Security# __________________________ Gender ______ Race_________________

Application for Grade __________________ Name of present school if other than Pillow _______________________________________
Students Address ______________________________________________
Home Phone ___________________________________
P.O. Box or Street
______________________________________________
City
State
Zip
Student Cell Phone _____________________________
Students e-mail___________________________________________
Has the applicant ever been expelled, denied re-enrollment at a school or counseled not to return to a school? __________________
If yes, please explain._______________________________________________________________________________________________
Has the applicant ever been the subject of any major school disciplinary action? _____________________________________________
Has the applicant ever bee n the subject of any law enforcement action? ___________________________________________________
Is applicant currently taking prescribed medications?_______ If yes, please provide the name of the medication__________________
Medical concerns or needs____________________________________________________________________________________________
Student #2s Full Name ____________________________________________________Preferred Name___________________________

Last
First
Middle
Date of Birth __________________________ Social Security# ________________________ Gender ______ Race__________________
Application for Grade __________________
Name of present school if other than Pillow ______________________________________
Home Phone ___________________________________
P.O. Box or Street
______________________________________________
City
State
Zip
Student Cell Phone _____________________________
Students e-mail___________________________________________
Has the applicant ever been expelled, denied re-enrollment at a school or counseled not to return to a school? ___________________
If yes, please explain.________________________________________________________________________________________________
Has the applicant ever been the subject of any major school disciplinary action? ______________________________________________
Has the applicant ever bee n the subject of any law enforcement action? ____________________________________________________
Is applicant currently taking prescribed medications? _____ If yes, please provide the name of the medication_____________________
Medical concerns or needs ____________________________________________________________________________________________

Last
First
Middle

Home Phone ___________________________________
P.O. Box or Street
______________________________________________
City
State
Zip
Student Cell Phone ________________________
Students e-mail___________________________________________
Is applicant currently taking prescribed medications? _____ If yes, please provide the name of the medication____________________
Last
First
Middle

Home Phone ___________________________________
P.O. Box or Street
______________________________________________
City
State
Zip
Student Cell Phone ________________________
Students e-mail___________________________________________
Is applicant currently taking prescribed medications? _____ If yes, please provide the name of the medication____________________
Fathers Full Name
_______________________________
Mothers Full Name
______________________________
Home Address
_______________________________
Home Address
_______________________________
_______________________________
_______________________________
Home Phone Number
_______________________________
Home Phone Number
_______________________________
Cell Phone Number
_______________________________
Cell Phone Number
_______________________________
Email
_______________________________
Email
_______________________________
Employer
_______________________________
Employer
_______________________________
Business Number
_______________________________
Business Number
_______________________________
Pillow Alumni
Year __________
Pillow Alumni
Year __________
Maiden Name
_______________________________
Check all that apply:
Student lives with
Parents Married
Single Parent
Parents Separated
Divorced
Joint Custody
Mother Deceased
Father Deceased
Mother & Father

Stepmother
Mother
Stepfather
Father
Guardian(s)
If parents are divorced or separated, to whom should correspondence be sent?
Both Parents
Mother
Father
Mother
Father
If parents are divorced, who has legal custody?
Joint Custody
Name of contact NOT at students home __________________________________________________________

Phone ______________________________
Physician ________________________________________________ Phone ______________________________
PAYMENT AGREEMENT: Please remember your $240.00 pledge or $20/month as long as a student is enrolled.
Registration Fee $200.00 due at registration
Plan I Payment by Month
Tuition Amt.
Monthly Payment
X No. of Students
Total
$ 4,300.00
$ 358.33
K4 & K5: All Day
_______________
$ _________________
$ 5,420.00
$ 451.67
Grades 1 - 5
_______________
$ _________________
$ 5,520.00
$ 460.00
Grades 6 -12
_______________
$ _________________
Pledge
$20.00
+ $20.00
Total of Monthly Payment
$ _________________
Plan I is a choice of monthly (May 2012-April 2013) drafts that will occur on dates indicated below or monthly post-dated checks
deposited on dates indicated below. Please circle the type of Payment and Preferred Date of Payments.
Bank Draft
Date of Drafts
Post Dated Checks

1st
5th
10th
15th
Enclose voided check if drafting payment
Date to Deposit Checks
1st
5th
10th
15th
Enclose 12 post-dated checks
Plan II Payment in Full

Tuition Amt.
Discount
Balance
X No. of Students
$ 4,300.00
$ 129.00
$ 4,171.00
K4 & K5
$ 5,420.00
$ 162.60
$ 5,257.40
Grades 1-5
____________
$___________
$ 5,520.00
$ 165.60
$ 5,354.40
Grades 6-12
____________
$___________
____________
Pledge
Total of Payment
Total
$___________
$240.00
$___________
Plan II is a One-Time payment for full tuition and pledge amount. Payment must be received by March 31, 2012 in order to apply
the discount. Plan II payment after March 31, 2012 will not receive the discount. All Payments in full must be received between
April 1 and May 31, 2012.

New Student Application for Pillow Academy

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New Student Application for Pillow Academy

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New Student

Application for Admission

Attention: Karen W. Makamson

69601 Highway 82 West

Student #1s Full Name ___________________________________________________ Preferred Name____________________________

Date of Birth _________________________ Social Security# __________________________ Gender ______ Race_________________

Home Phone ___________________________________

P.O. Box or Street

Student Cell Phone _____________________________

Student #2s Full Name ____________________________________________________Preferred Name___________________________

Name of present school if other than Pillow ______________________________________

Students Address ______________________________________________

Home Phone ___________________________________

P.O. Box or Street

Student Cell Phone _____________________________

Student #3s Full Name ___________________________________________________ Preferred Name____________________________

Date of Birth __________________________ Social Security# ________________________ Gender ______ Race__________________

Name of present school if other than Pillow ______________________________________

Students Address ______________________________________________

Home Phone ___________________________________

P.O. Box or Street

Student Cell Phone ________________________

Date of Birth __________________________ Social Security# ________________________ Gender ______ Race__________________

Name of present school if other than Pillow ______________________________________

Students Address ______________________________________________

Home Phone ___________________________________

P.O. Box or Street

Student Cell Phone ________________________

Fathers Full Name

Mothers Full Name

Home Phone Number

Home Phone Number

Cell Phone Number

Cell Phone Number

Check all that apply:

Student lives with

Mother & Father

If parents are divorced or separated, to whom should correspondence be sent?

If parents are divorced, who has legal custody?

Name of contact NOT at students home __________________________________________________________

Physician ________________________________________________ Phone ______________________________

K4 & K5: All Day

Total of Monthly Payment

Post Dated Checks

Enclose voided check if drafting payment

Date to Deposit Checks

Enclose 12 post-dated checks

Plan II Payment in Full

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Student #1s Full Name _______________________ Preferred Name

Date of Birth _____ Social Security# Gender Race_

Student #2s Full Name __________________________Preferred Name_

Student #3s Full Name _______________________ Preferred Name

Date of Birth ______ Social Security# Gender Race

Date of Birth ______ Social Security# Gender Race

Physician __________________ Phone