Naylor Road School 2403 Naylor Road, S.E. Washington, D.C. 20020 (202) 584-5114

Application for Admission Grades Kindergarten - Gr. 8

Date_________________

Child's Full Name__________________________________________________________

Entering Grade_____________________

Date of Birth______________________    ____Boy    ____Girl

Father	Mother
___________________________________ Full Name	___________________________________   Full Name
___________________________________ Home Address (number & street)	___________________________________   Home Address (number & street)
___________________________________ City            State      Zip Code	___________________________________   City            State      Zip Code
___________________________________ Home Telephone Number	___________________________________   Home Telephone Number
___________________________________ Employer	___________________________________   Employer
___________________________________ Work Telephone Number	___________________________________   Work Telephone Number

Serious Illnesses__________________________________________________________

Serious Allergies__________________________________________________________

Physician's Name & Phone No._______________________________________________

School Previously Attended_________________________________________________

Emergency Contact Name & Telephone No._____________________________________

If divorced/seperated, the child resides with______________________________

Name of person to whom bills will be sent__________________________________