EFTA01265810.pdf

PG PROFESSIONAL CHILDREN'S SCHOOL Please include $40 non-refundable Application Fee. Admission is not completed until the applicant has been accepted by the School and an enrollment contract has been signed by both the parent and the school. All sections must be fully completed (section 3, if applicable). Please print or type. Date -l%//9, SECTION A. [ [Mate Female Name of student (legal name) S514 Grade applied for (2- For entrance (month/year) Date of birth Birthplace (city/state) Newport, ghate . k4rict or Permanent address Local address City/state/zip City/state/zip lelephc Telephone ( ) Fax Fax ( SECTION B. Applicant's present school Current Grade Telephone ) ounse or s pnncipa s name Ed ratIn Grades/date attended Reason for leaving moved -to lq eGO Kirk. Previous Schools Attended (in reverse chronological order): I. Name Address _ Counselor's/principal's name ea.c. j e 417 Grades/dates attended Reason for leaving ith itertoGiy beerkirtn;.ozy COILS a 4 oo / 1. Name NN(ANS Address Counselor's/principal's name Grades/dates attended Reason for leaving SDNY_GM_00005511 CONFIDENTIAL PCS0000020 EFTA_00119574 EFTA01265810 SECTION C. Father's name Mother's name Father's address Mother's address City/state/zip City/state/zip 'telephone ( Telephone Fax ( Fax Father's occupation/position Mother's occupation/position ..r11461i or DeCOra.rtir Name of father's firm Name of mother's firm sac eowtflOTa ,n Business address Business address it 'telephone Telephone Fax Fax ( it ) Parents: ( ) Living togler [ ] Separated [ ] Divorced [ l Father remarried ( )Mother remarried bI gtvl Othe r is WI ol, 01.41 4// Stepmother's name Stepfather's name SECTION D. Required for students who live away from home. Guardian's name Name of business Guardian's address Business address lelephone ( Business telephone ( Fax ( Relationship to student Occupation/position SECTION E. Who has financial responsibility? M. r • "3- 4r Eps+e Address 'is- 7- Mattison Rye. inn! City/state/zip 14W 16 ter, ) N •Ye 10027 Bank reference (name and branch) J. P. Mari a. in) 5 111 Alit - Do you expect to apply for financial assistance? [ ) Yes %) No SECTION F. Other children in family • Name Age School Attending Grade SDNY_GM_00005512 CONFIDENTIAL PCS0000021 EFTA_00119575 EFTA01265811 SECTION G. Have you any relatives who attended PCS? No Name Relationship aass (If known) SECTION H. How did you become interested in PCS? (List name and address if applicable.) The president ar achviessions cif The Ithitiard Schaaf, MS- May ("Kay' referred me -to your School- SECTION I. Student History Does the student have an illness or disability which would limit his/her school activities? [ ] Yes X] No Please explain. Has student's school attendance been intenupted for a period of a month or more due to medical reasons? [ ] Yes fo() No Please give reasons and approximate dates. Name of Telephone Has the candi ate s ip or repea a gra es [Y] No Please indicate the grade(s) and the circumstances. Has the candidate ever attended summer school? [ ] Yes NI No Give the name and address of the school, the subjects taken, and the reasons for attending. Has the candidate had special tutoring? [ ] Yes (Y.,1 No Please indicate the subject(s), the grade(s), when the candidate was tutored, and the circumstances. Describe any special circumstances which have affected the candidate's performance in school (for example, learning disabilities, illness, physical handicaps, or frequent changes of home or schools). — NONE SDNY_GM_00005513 CONFIDENTIAL PCS0000022 EFTA_00 I 19576 EFTA01265812  SECTION J. If the student is "Professional" or "Pre-Professional," please fill out this section. Professional name Student's professional goals: Achre-ss /s1nyr I Ma de I Student is presently studying: [ ] Dance (type) 1,40 Music (instrument) VOICe :"Sc/prztric, p<1 Drama [ ] Sports (specify) Name of professional institution &its giL c Name of Instructor Mr C. Address 6 — CA-44...tOnSc:t • we Sts1 City/state/zip New York / MI Y. 0 003 Telephone Length of attendance Please list other professional instructors and schools (include dates attended): Der Yr00 S SCI-100L- Or Ptg:15 vo(ce t Ti-torrez MR.3-0e, 1•NrieeLacHew ARTS CA MP s'iti;4571(0. Netzwoop imstrru 19-.) Sotell aSavtYajo —voice -1-ectcher is) *Pet tbn stack °tem..- Ahlbn 6w:tactic) - itatce tbnstriA.c-f-trg. - 91? etc. Describe performing or professional experience (recitals, commercials, films, shows, television) and list dates or include resume: See 4.44-ctowet Name of agent, manager or agency: Is applicant presently working? [ ] Yes },0 No Describe job. M. Ve Ca_sty Address 5 Lufttovi St • WCS* Name of employer City/state/zip Nevi 61-k ( Ilk 10003 Address Telephone •I City/state/zip Union affiliation Telephone ( Does 'father or ) mother work in the performing arts? If so, please give professional name(s): SECTION K. Candidate's signature Date 6-7 78 Parent's (or guardian' Father Date Date 4/ 2c/181 Pro teligion. sex, and national surd ethnic origin to all the rights, prhiloges, programs and activities generally accorded or made available to students at the School It does not discriminate on the basis of color, religion, sex or 'redcoat and ethnic origin in administration of its educational policies, telteriarship and loan programs, cc athletic and other school administered programs Neese mall this form to: Director of Admissions, Professional Children's School, 132 West 60th Street, New York, N.Y.10023. Meek you. SDNY_GM_00005514 CONFIDENTIAL PCS0000023 EFTA_00119577 EFTA01265813