STATEN ISLAND ACADEMY
715 Todt Hill Road, Staten Island, NY 10304
718.987.8100 Fax 718.979.7641
www.statenislandacademy.org

William Winter Scholarship Application for Admission, Grades 6 and 9

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* indicates required field
Applicant for Academic Year:
for Grade*:
Child's Name (First, Middle and Last)*:
Child's Nickname:
Birthdate:
Place of Birth:
Male Female  
Languages Spoken by Family
in addition to English:
Current School:
Current Grade:
Dates in Attendance:
Present School Address:
City:
State: Zip Code:  
Previous School Attended (#1):
Dates in Attendance:
Previous School Attended (#2):
Dates in Attendance:
Previous School Attended (#3):
Dates in Attendance:
Has Applicant Previously Applied to S.I.A.? Yes No
If yes, Date(s)

Sibling Information
Sibling (#1):   Sibling (#2):  
Name: Name:
Age: Age:
School: School:
Grade: Grade:
Sibling (#3):   Sibling (#4):  
Name: Name:
Age: Age:
School: School:
Grade: Grade:

Family Information
Applicant's Parent (#1): Applicant's Parent (#2):
Title: Title:
Full Name*: Full Name:
Marital Status: Married Separated Divorced Marital Status: Married Separated Divorced 
Home Address*: Home Address:
City*: City:
State*: State:
Zip Code*: Zip Code:
Phone(Day)*: Phone(Day):
Phone(Evening): Phone(Evening):
E-mail*: E-mail:
Business Name: Business Name:
Position: Position:
Business Address: Business Address:
City: City:
State: State:
Zip Code: Zip Code:
Business Phone: Business Phone:
High School: High School:
College(s)/Degree(s): College(s)/Degrees:
If parents are divorced or separated, with whom is the applicant living?
If parents are divorced or separated, should both parents receive mailings? Yes No
Name and Address for bills to be sent: Guardian's Name and Address (if applicable):
Full Name: Full Name:
Address: Address:
City: City:
State: State:
Zip Code: Zip Code:


How did you hear about Staten Island Academy?
Friends/relatives who attended Staten Island Academy:
Has Applicant Attended Staten Island Academy Day Camp? Yes No
If so when (mo/yr)
Do you have results from any educational or psychological tests you would like to include with your child's application? Yes No

What do you hope your child will gain from a Staten Island Academy education?


A $25.00 application fee is required with your application.


Product Description Cost Quantity
online ww scholars admissions application fee $25.00

By submitting this form, I the parent/guardian, give permission for Staten Island Academy to contact any previous schools the applicant has attended.