Online Application

Candidates Full Name *

Gender * Male Female

Date of Birth

Country of Birth

Country of Citizenship *

Home Address *

City *

State/Province *

Zip

Country *

Primary Contact Phone Number *

Additional Phone Number

Primary Contact E-mail Address *

Current Grade Level *

Intended Enrollment * Fall Spring Summer Other

Name of Present School

Present School Address

City

State/Province

Zip

Phone

Father's Name

Address

State

Zip

Home Phone

Alternate Phone

Company Name

Occupation / Title

Work Phone

E-Mail

Mother's Name

Address

State

Zip

Home Phone

Alternate Phone

Company Name

Occupation / Title

Work Phone

E-Mail

Candidate Lives with (Check all that apply) Mother Father Step Mother Step Father Other

If lives with Other, specify
Address

City

State

Zip

Home Phone

Alternate Phone

Citizenship * Please Select US International

Please describe your student's academic strengths*

Please describe any of your student's academic weaknesses*

Please describe what makes your student different from other students their age*

Please tell us why we should accept your student over other applicants*

If you are a International Student are you working with an Agent? Please Select Yes No

If Yes, please specify
Name of Agency

Name of Agent

E-mail Adress of Agent

Phone Number of Agent

Were you referred to Fieldstone by an Educational Consultant? Please Select Yes No If Yes who?

By submitting this form I attest that the above information is true to the best of my knowledge. I also authorize Fieldstone Academy to release any information required to process my claims. I understand that any false or missing information on this application can result in my child being returned to me at my expense and that any deposits or payments made to Fieldstone Academy would then be forfeit. I further state by clicking "Finish" that I understand the nature of educational institutions and that such institutions cannot guarantee results, GPA levels, or college acceptance. Such results are also dependent upon the participation of the student.