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Application

Please Note: a Non-refundable $75 application fee must be received at Chesterfield Day School before your application will be processed. Please mail or deliver your application fee separately, or call the Admissions Office to arrange payment over the phone.

	Applicant's First Name*

	Applicant's Last Name*

	Applicant's Middle Initial

	Enterting Grade

	Application for Academic Year

	Applicant's Gender

	Home Address Line 1*

	Home Address Line 2

	City*

	State*

	Zip Code*

	Male/Female

	Date of Birth (mm/dd/yyyy)

	Home Phone Number*

	Mother's Cell Phone

	Father's Cell Phone

	Mother's Email

	Father's Email

	Present School

	Present Grade

	Years Attended

	Present School Address

	City

	State

	Zip

How did you first hear of our school?

	Word of Mouth
	Educational Consultant
	Placement Officer
	School Fair
	Advertisement
	Internet
	Other:

Applicant Lives With *

	Mother and Father
	Mother
	Father
	Other:

	Non-Custodial Parent's First Name

	Non-Custodial Parent's Last Name

	Non-Custodial Parent's Address

	City

	State

	Zip

	Mother's Employer Name

	Address

	City

	State

	Zip

	Employer Phone Number

	Father's Employer's Name

	Address

	City

	State

	Zip

	Employer Phone Number

	Mother's College Attended

	Mother's Highest Degree Obtained

	Father's College Attended

	Father's Highest Degree Obtained

	Siblings' Name/ Birth Date/ Current School/ Grade

	Siblings' Name/ Birth Date/ Current School/ Grade

	Why have you chosen Chesterfield Day School for your child?

	What are your goals for your child's education?

	Describe any physical condition(s) or learning/emotional difficulties that might affect your child's full participation in the Chesterfield Day School program.

	Describe any problems experienced at any school previously attended?

Please Note: Questions marked with an asterisk (*) are required.

Mrs. Marjorie Caldwell
314.469.6622 x254

mcaldwell@chesterfielddayschool.org