Application  for  Admission  to   Mt.  Blue  Campus     To  be  considered  for  admission  to  Mt.  Blue  Campus,  you  and  your  child  must  complete  this   application  with  the  appropriate  signatures  and  return  it  to  our  representative.     The  required  documents  for  submission  are:     • A  completed  application  in  English.    All  the  information  must  be  true  and  accurate.    The   application  must  be  printed,  signed  by  the  student  and  parent/guardian,  and  converted   into  a  PDF  file.   • An  essay  of  300  words.    It  must  be  typed  and  signed  by  the  student  applicant.   Please  choose  from  one  of  the  following  topics:   1.  What  person  or  event  has  had  a  particular  impact  on  your  life?    Why  is  this   person  or  event  so  important  to  you?   2. Why  do  you  want  to  attend  Mt.  Blue  Campus?   3. Please  describe  what  makes  you  a  unique  individual  and  how  these  qualities   will  benefit  Mt.  Blue  Campus.   • TOEFL  or  other  accepted  English  proficiency  test  results.   • Transcript  of  previous  two  grade  levels  (in  English)  with  school  stamps  and  school   contact  information.   • Two  letters  of  recommendation  from  English  and  math  teachers  with  signatures  and   contact  information.   • Bank  statement  showing  a  deposit  of  at  least  an  equivalent  of  $30,000  USD  to  cover  the   cost  of  tuition.   • Any  other  certificates  of  special  talent  or  awards  (must  be  translated  into  English).   • Copy  of  most  recent  passport  with  photo  page.   • $50  non-­‐refundable  application  fee  payable  to  the  Mt.  Blue  Regional  School  District.      

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    Student’s  Full  Name:  ________________________________________________________________     Current  School:  _____________________________________________________________________     Grade  Level:  ____________    Home  Schooled:    _______  Yes    _______  No     Applying  for  grade  (check  one):  _____  9    _____  10    _____    11    _____  12   ___________________________________________________________________________________    

Personal  Information  

To  be  completed  by  the  student  and  parent/guardian     Student’s  Full  Name:  ________________________________________________________________         (Family/Surname)       (First)       (Middle)     Gender:  _________  Male    _________Female   Nationality:  ________________________________     Date  of  birth:  ________________________   Place  of  birth:  ______________________________     Residential  Address:  ________________________________________________________________             (Box,  Apartment,  Street  name  &  number)     ____________________________________________________________________________________________________     (City)         (State/Province)       (Country)     (Postal  Code)    

Mailing  Address:  ___________________________________________________________________   (If  different  than  residential)      

 

 

 

(Box,  Apartment,  Street  name  &  number)  

__________________________________________________________________________________                    

(City)  

 

 

 

(State/Province)  

 

 

(Country)    

(Postal  Code)  

Home  Phone:  ________________________________   Other  Phone:  ________________________   Student  Email:  _______________________________   Skype:  ______________________________     With  whom  do  you  live?    _____  Mother  and  Father    _____  Mother    _____  Father    _____  Legal  Guardian              _____  Father  &  Stepmother    _____  Mother  &  Stepfather     ______  Other  (Specify):  ______________________________________________________________      

Primary  Language   What  language  did  you  first  learn  to  speak?  _________________________________________________   What  language  is  spoken  at  home?  ________________________________________________________   What  language  is  spoken  most  by  your  parents?  _____________________________________________        

 

 

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    Parent  Information     Father/Guardian  Name:  _________________________________________________________________                     (Family/Surname)         (First)    

Father/Guardian  Address:  _______________________________________________________________   (If  different  from  applicant)    

Home  Phone:  _________  Cell  Phone:  _________          Father/Guardian  Employer:  ___________________     Mother/Guardian  Name:  ________________________________________________________________           (Family/Surname)         (First)    

Mother/Guardian  Address:  ______________________________________________________________   (If  different  from  applicant)    

Home  Phone:  _________  Cell  Phone:  _________          Mother/Guardian  Employer:  __________________     Primary  Email:  ___________________________      

Emergency  Contact    

Please  list  any  relatives  residing  within  the  USA     1.     _____________________________________________________________________________________   (Family/Surname)        

 

 

(First)  

 

 

(Relationship  to  applicant)  

 

(Phone)  

2.     _____________________________________________________________________________________   (Family/Surname)        

 

 

(First)  

 

 

(Relationship  to  applicant)  

 

(Phone)  

 

About  You   Please  list  any  extracurricular  activities  in  which  you  have  been  involved  (e.g.,  athletics,  clubs,  student   government,  music,  art):   _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________  

 

 

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Have  you  participated  in  any  criminal  offense?    _______  Yes    ________  No   Have  you  participated  in  any  incident  leading  to  suspension  or  expulsion?  _______  Yes  ________No   Have  you  received  any  other  discipline  infractions?  __________  Yes  _________  No   If  you  answered  yes  to  any  question,  please  explain  in  detail:   _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________  

 

 

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Essay    

An  essay  of  300  words  must  be  typed  and  signed  by  the  applicant.    You  may  attach  a  separate   sheet  if  needed.     Please  choose  from  one  of  the  following  topics:     1. What  person  or  event  has  had  a  particular  impact  on  your  life?    Why  is  this   person  or  event  so  important  to  you?   2. Why  do  you  want  to  attend  Mt.  Blue  Campus?   3. Please  describe  what  makes  you  a  unique  individual  and  how  these  qualities  will   benefit  Mt.  Blue  Campus.                                                     With  my  signature,  I  acknowledge  that  this  application  is  my  own  work  and  that  I  did  not   receive  any  assistance  in  answering  these  questions.     Student  Signature:  ___________________________________    Date:______________________    

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