Registration Form

Interested in joining the Hermiston Jr Academy family? Please fill out the form below.

Student Information

First Name

Middle Name

Last Name

Birthday

Age

Gender

Place of Birth

Student Baptized SDA?

Baptism Date

Student lives with: (Mark all that apply) Father Mother Stepfather Stepmother Grandparent Other (Please fill in following box)

Lives with other:

Parent/Guardian 1

Relation to Student:

Legal Name

Address

Cell Phone

Work Phone

Home Phone

Occupation

Employer

Parent/Guardian 2

Relation to Student

Legal Name

Address

Cell Phone

Work Phone

Home Phone

Occupation

Employer

Emergency Contact 1

Name

Relation

Cell Phone

Work Phone

Home Phone

Emergency Contact 2

Name

Relation

Cell Phone

Work Phone

Home Phone

Emergency Contact 3

Name

Relation

Cell Phone

Work Phone

Home Phone

After School Pickup

List all approved for after school pickup