Apply Online

If you would like to fill out the application by hand, download this Admissions Application
and send it in with the $50 application fee to Keith Country Day School, 1 Jacoby Place, Rockford, IL 61107, Attention: Admissions Office. If you have any questions, contact Rachel Rebsom at
rachel.rebsom@keithschool.net or 815-399-8850, ext. 197.

APPLICANT

Applicant’s Name
Preferred First Name
Entering grade in 20 Birth date // Gender  Male Female
U.S. Citizen?  Yes No Country of origin
Present School (if any)
Present School Address Present Grade
Dates Enrolled Public School District
Race/Ethnicity (optional – please check all that apply)

 African American Asian American European American Hispanic American Native American Middle Eastern American Multiracial American Pacific Islander American Other

PARENTS

PARENT/GUARDIAN NAME
 Mr. Ms. Mrs. Dr. Rev.
Name
Home Address


Phone
E-mail
Occupation
Company
Business Address


Business phone
E-mail

2ND PARENT/GUARDIAN NAME
 Mr. Ms. Mrs. Dr. Rev.
Name
Home Address


Phone
E-mail
Occupation
Company
Business Address


Business phone
E-mail

Please note if parents are separated, divorced, or if either is deceased
Who has legal custody of the applicant? With whom does the applicant live?
Who is responsible for financial obligations?
Do you plan to apply for merit-based tuition assistance (available in grades 5-12 only)?  Yes No
Do you plan to apply for need-based tuition assistance (available in grades K-12 only)?  Yes No
If yes to need-based, complete the Parents’ Financial Statement at online.factsmgt.com/aid

FAMILY

Applicant’s Siblings
Name date of birth school grade
Name 2 date of birth school grade
Name 3 date of birth school grade

Applicant’s relatives now or formerly connected with Keith Country Day School (alumni/ae, trustee,
students, etc.)
Relative 1 relation dates of attendance (if applicable)
Relative 2 relation dates of attendance (if applicable)

Applicant’s Grandparents
Maternal Name(s)
Address


Paternal Name(s)
Address

GENERAL

Has this applicant applied to or attended Keith Country Day School before?  Yes No
Other schools to which applicant is applying:
Please describe briefly any particular circumstances regarding the applicant’s performance in school (e.g.
health, learning style, frequent change of schools, skipped or repeated grades). Please include dates.

Has the applicant been found responsible for a disciplinary violation at any educational institution that resulted
in probation, suspension, removal, dismissal, or expulsion?

Has the applicant been referred for or undergone an educational or psychological evaluation in the last five
years?
Does the applicant have an accommodation plan or IEP?  Yes No
Describe any physical, emotional, or mental condition of which the school should be aware.

The information contained in this application is true and accurate to the best of my knowledge. If the
answer to any question is later rendered incorrect by subsequent events, I agree to immediately notify
the Admissions Office in writing. I understand that any falsification/omission on the application will
disqualify my child from further admission consideration or withdrawal of any offer of admission and
possible tuition assistance.

Please Pay $50 application fee after clicking submit!