ALEXANDER-SMITH ACADEMY APPLICATION FOR ADMISSION 10255 RICHMOND AVENUE #100 HOUSTON, TEXAS 77042 off.(713) 266-0920 fax (713) 266-8857 www.alexandersmith.com International Application, request for student visa, current transcripts, passport, immunization records, and a non-refundable $500 application fee must accompany this completed application. Applicant s Full Name
Alexander-Smith Academy 10255 Richmond Ave Houston, Texas 77042-4177 713/266-0920 Fax 713/266-8857 www.alexandersmith.com Application for International Students and Request for a Student Visa Student Information: Please fill a form for each student requesting a student visa. Family Name: Middle Name: First Name: Country of birth: Country of Citizenship: 1) 2) Date of birth: \ \ Grade for which the student visa is requested: DD\MM\YYYY U.S. cell phone number ; U.S. email address Expected Graduation Date: Student s Passport Number: (Please attach a photo copy of passport to this application) Parent Information: 1) Relationship to Student: Family Name: Middle Name: First Name: 2) Relationship to Student: Family Name: Middle Name: First Name: International Address Address: Country: Postal Code: Home Phone: Mobile Phone:
Guardian Information (must be a Texas resident) Family Name: Middle Name: First Name: Address: City: State: Zip Code: Guardian s relationship to student Guardian s Passport Number Home Phone: Work Phone: Mobile Phone: Guardian s email Employer: Position: Work Address: City: State: Zip Code: If the student will be living with a parent(s), what visa does the parent(s) currently hold? Reason for Visa Please state your reason for a visa request/change of visa status: Please note: All students requesting a student visa are required to pay full tuition and fees before Alexander-Smith Academy will process an I-20. Alexander-Smith Academy s program officer will meet with parents and guardian/texas resident in person when the file is created. Alexander- Smith Academy is mandated to update student files at the beginning of each term, and know of travel plans in advance. Guardians and students will be made aware of the visa program requirements. Parent Signature: Date: Guardian Signature: Date: Program Officer: Date:
PERSONAL INFORMATION How did the applicant hear about ASA? Has the applicant been enrolled in any accelerated courses? If yes, please list courses, grades: Has the applicant s school attendance been regular? If no, please explain. Has the applicant been tested for academic or behavioral concerns? If yes, please indicate: ADD ADHD Dyslexia Other (Please explain) A COPY OF TEST RESULTS MUST ACCOMPANY THIS APPLICATION. Has the applicant ever been referred to Educational Services for learning differences? If yes, please explain: Has the applicant ever received psychological or personal counseling? If yes, please explain. Are there any prior or continuous emotional or behavioral problems which ASA should be aware of in order to work successfully with the applicant? If yes, please explain.
If the applicant is on medication, please indicate what medication and dosage. Will it be necessary for an ASA advisor to dispense medication during the school day? Is there any health information the school should know? If yes, please explain. Name of applicant s physician: Phone: In case of emergency, please list who should be contacted and their phone number, in the order of preference: OTHER REQUIRED INFORMATION 1. Have you ever been found responsible for a disciplinary violation at any secondary school you have attended, whether related to academic misconduct or behavioral misconduct that resulted in your probation, suspension, removal, dismissal, or expulsion from the institution? Yes No 2. Have you ever been convicted of a misdemeanor, felony, or other crime? Yes No 3. Are you or have you ever been on probation for a misdemeanor, felony or other crime? Yes No If you answered yes to either or both questions, please give the approximate date of each incident and explain the circumstances. If necessary, attach a separate piece of paper.
RELEASE OF RECORDS By signing this application I authorize Alexander-Smith Academy to request any records or documents from previous schools attended or educational consultants if deemed necessary. ACCURACY DISCLAIMER My signature on this application verifies that to the best of my knowledge, the information given in the application is true and complete. I also affirm that I shall immediately notify Alexander-Smith Academy of any changes to the information given in this application. I authorize the school to verify any information given in this application should it so desire. I understand that if any information given in this application is false, it may result in the immediate expulsion of my son/daughter. Parent Signature REFUND POLICY THERE ARE NO TUITION REFUNDS. In the event a student withdraws or transfers, payments are discontinued as of that date. If an international student is not permitted through a U.S. port of entry by a U.S. official, then the tuition will be entirely refunded. This page is to be handwritten by the applicant. STUDENT PROFILE Name: Nickname: Please list extra-curricular activities in which you have participated while attending high school: What is your favorite class? Why? What is your least favorite class? Why?
What do you like to do after school or on weekends? What is the name of the last novel you read that was not a school assignment? Please tell us anything about yourself that would help the Faculty of ASA get to know you and help us work with you: Briefly describe any voluntary community service you have done and how that activity has contributed to the betterment of society: Write a short essay below describing how you think you would benefit from an education at ASA.