St. James Episcopal School Questionnaire

Applicant's Namerequired

First Name

Middle (optional)

Last Name

Applicant's Date of Birthrequired

Must contain a date in M/D/YYYY format

Person Completing the Formrequired

First Name

Last Name

Email Address of person completing this form:required

Medical/Health History

Has your child had any of the following health conditions?required

check as many as necessary

Who is your child's primary physician?required

get frustrated easily?requiredPlease select up to 1 choice

yes

no

sometimes

Please select up to 1 choice

Areas of Overall Development:

Please check all areas of concern:required

What do you want your child to get from his/her school experience?required0 / 1000

Is there anything else you would like to share with us?0 / 1000