428 Harmon Road – PO Box # 1467       423-526-2807                        

New Tazewell, TN   37824     glloyd@heritageba.com                                                                                                                                                   

Application Fee $25.00                                                                                                   

                        STUDENT APPLICATION 

$25.00 APPLICATION FEE  MUST ACCOMPANY APPLICATION**

Date:                                                               Grade applying for:                                        

Student’s Name:                                                                                 ____                           

(Please Print or Type)                  (Last)                                                (First)                                                    (Middle)

Address:                                                                                                                                    

                             (Street)                                                    (City)                                                (State)              (Zip)

Phone #                                                              E-mail                                                            

Birthday:                                    Place of Birth  _____________________________ ______  

                                                                                                        (City)                                   (State)     

                             Parent(s) or Guardian(s) with whom the child is now living:

Father:                                                                          C-phone #                                              

Mother:                                                                         C-phone #                                                                                                                                              

Occupation and Place of Employment:

Father                                                                            Phone # (      )                        

Employment                                                                  Phone # (      )                        

Mother                                                                          Phone # (      )                        

Employment                                                                  Phone # (      )                        

Name(s) of Emergency Contacts

                                                                                       Phone # (      )                        

            Name                                                      Relationship

                                                                                       Phone # (      )                                    

           Name                                                       Relationship       

**$25.00 Application Fee is for first-time students only.

Does the applicant have any physical, medical, emotional or learning disabilities?     Yes____   No_____

If yes, please provide specific information:

Was applicant ever enrolled in and/or recommended for any Special Learning Classes?  Yes         No___

Has applicant ever repeated a grade?  Yes_____   No_____              School applicant last attended:

            (Name of School)                                                (Street)                                               (City)                                                  (State)

Has the applicant ever been dismissed or suspended from any school?    Yes   No_____

If so, please explain:                                                                                                                                    

Please list the names of preschool and school age children in the family:

                                            (Name)                                                                                                               (Age)                              (Grade)

Name of Church Attended                                                                                                                                 

Pastor’s Name                                                                                                                                                

Please read carefully and sign below indicating a sincere desire that your child become or remain a student at Heritage Baptist Academy:

            Heritage  Baptist  Academy  admits students  of  any  race,  color,  national and

ethnic origin to all the rights, privileges, programs, and activities, accorded or made available to students at the Academy.  HBA does  not discriminate, on the basis of race, color, national or ethnic origin, in administration of its educational policies, admission policies, scholarships, loan programs,  athletic or other school administered programs.  HBA reserves the right to accept or reject an applicant for any reason or no reason.

   In making this application, I/we understand that, if my/our child is admitted to 

HBA, I/we will fully support the purpose, philosophy, principles, policies, and procedures as outlined in the Academy Handbook.  I/we will accept the mission of HBA to provide a Christ-centered education to equip my/our child spiritually, academically, and physically for today and eternity.

                                (Parent/Guardian Signature)                                                                       (Date)

                                    (Parent/Guardian Signature)                                                                              (Date)