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Student Profile

. COMPLETE LA FORMA EN ESPAÑOL .
   

Please complete this form if your are applying for admission to Wentworth.  If you would simply like more information on the school, click here.

TERM APPLYING FOR:

Camp LEAD 2008

High School Scholars Program, Academic Year 2008-2009

Accelerated Scholars Program, Academic Year 2008-2009

Military College (SROTC), Academic Year 2008-2009

Military College (not SROTC), Academic Year 2008-2009

What Grade Are You Applying For? 

  STUDENT INFORMATION:

Name of Applicant:*
(Last) (First) (Middle)
Date of Birth:* / / Age: 
 
Preferred Nickname:  
Gender:* Male Female  
Address:*  
  (Street Address)  
   
  (City, State & ZIP)  
Phone:*  
Citizenship:  
Country of Birth:  
Dual Citizenship?  Yes  No  
International Students Only* Are you a U.S. Citizen but reside primarily outside the U.S?  Yes No

Are you a citizen of another country currently living in the U.S.?  Yes No 

Which country is your primary residence? 

FAMILY INFORMATION:
 

Parent/Guardian 1
Relationship to applicant:*   Name*:
Home Address (if other than cadet):*
E-mail address:* 
Home Phone:*   Cell Phone:*
Fax:
Profession:   Employed by:
Business Phone:*
 

Parent/Guardian 2
Relationship to applicant:   Name:
Home Address (if other than cadet):
E-mail address: 
Home Phone:   Cell Phone:
Fax:
Profession:   Employed by:
Business Phone:
 

PART 4:  APPLICANT DISCLOSURES

*Has the applicant ever received counseling or assistance for emotional, physical, medical, or behavioral problems that may affect the ability to live away from home in a rigorous, highly structured and competitive college preparatory environment, including but not limited to the following (check all that apply, and please explain below):

 NONE OF THESE APPLY
Drug or alcohol use; cigarettes or other tobacco products; or misuse of over-the-counter medications
Depression or low self-esteem
Suicide
Eating or other compulsive disorders                                                       
Food allergy (peanut, for example?)
Confrontational or violent behavior; problems with authority
Self destructive behavior
ADD / ADHD
Oppositional Defiant Disorder (ODD)
Any other disorder, physical limitation or behavior?  Possible examples include, but are not limited to: bi-polar disorder, autism, anxiety attacks, epilepsy, hallucinations, diabetes, phobias, and bed wetting.

*If you checked any of the options above please explain further:

*If your child is taking medication, please explain further:

*Does the applicant have any record of involvement with law enforcement or civil authorities – either current or in the past, adult or juvenile – and is the applicant now or has at any time in the past been on probation? (The following is included: any arrest, charge, citation or detention for any violation, even those now expunged and/or the existence of a SIS).

YES  NO

Please Explain:

*I have read and understand the Statements of Understanding

The Student Profile is the first step in applying to Wentworth.  Click here to to learn more!