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Charter High School Student Application

• All Fields are required

First Name:

Resident School:

Middle Name:

Student #:

Last Name:

Current Grade:

Date of Birth:

Age:

Sex:

Grade Upon Entering:

Home Address :

Mailing Address
(if different than home) :

City :

City:

Zip:

Name:

Mother Guardian

Home Phone:

Cell Phone:

Place of Business:

Work Phone:

email:

Name:

Father Guardian

Place of Business:

Work Phone:

email:

Race:

American Indian Asian/Pacific Islander Black,Non Hispanic

Hispanic White,Non Hispanic Multi Racial

Other Race:

Medical History

Your child will be required to operate various tools and equipment. Once accepted to the Riviera Beach Maritime Academy a complete medical summary must be completed. A physician’s approval and signature stating that any prescription medications your son/daughter may be taking will not affect his/her ability to operate tools and equipment.

Make sure all your child's vaccinations are up to date. No Shots, No School, No Kidding.

This application and Student Interest must be completed by the student, and signed by the parent or guardian. The Guidance Information
must be completed and signed by the resident schools guidance counselor or approved school personnel. Please turn in 3 teacher recommendations along with this application.

I have discussed the above application with my son/daughter and hereby give my permission for him/her to apply to the Riviera Beach maritime Academy

Parent Guardian Name:
(serves as electronic signature)

Student Name:
(serves as electronic signature)

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