Today's Date:



STUDENT INFORMATION:
Last Name

First Name

Middle Initial

Current Street Address

City

State

Zip

Home Phone

Student Birthplace

Date of Birth

Student Age

Student Sex
MaleFemale
Relation Status
Natural ChildAdopted Child
Grade to enter

Year to begin

School District

FAMILY INFORMATION:
Father Info:
Father's Name

Address (If different from student)

E-mail address

Employer

Cell Phone Number

Mother Info:
Mothers name

Address (If different from student)

E-mail Address

Employer

Cell Phone Number

Marital Status:
MarriedSingleSeparatedDivorcedWidowed
Emergency Contact

Relation to student

Emergency Phone

Student's Physician

Physician Address

Physician Phone



List names of other children living in the household with ages and school attending:

Is there any other information the school needs to be aware of for your child's protection and safety?



ACADEMIC INFORMATION:
List Information about previous schools student attended (begin with most recent):
School Name

School Address

School Phone

School Fax

Student's Grade Averages:
A'sB 'sC'sD'sF's


Additional Schools (if necessary):
School Name

School Address

School Phone

School Fax

Student's Grade Averages:
A'sB 'sC'sD'sF's


Please check the following below if it applies to your child:
repeated grade(s)has any permanent physical handicaptaking any medicationsbeen expelled, suspended from schoolreceived special needs instructionbeen diagnosed as learning disabledhad physical difficultiesabused drugs, tobacco, alcoholexhibited learning problemsWas part of a gifted program
Please explain any of the above:


CHURCH AFFILIATION:
Name of Church

Name of Pastor

Church Address

Church Phone

Are you church members?
YesNo
Attendance:
Weekly (or more)BiweeklyMonthlyOccasionally
Student's Attendance in Sunday School:
RegularlyOccasionallyNever
What areas are you involved in?
Parent:

Student:



OTHER INFORMATION
Reason for selecting this school:



Since we teach a Bible-based curriculum and are a ministry to Christian families, we ask that at least one parent
be a born again, committed Christian. With this in mind, we would like a brief explanation of your coming to
faith in Christ as your personal Saviour and Lord.





In making this application, we understand that:
1. I/we agree to abide by the discipline guidelines as outlined in the parent/student handbook.
2. The administrator has full responsibility for placing my child in the proper grade.
3. Our full cooperation is expected in: a) regular tuition payments, b) practical help, and c)
spiritual and educational support.
4. The school reserves the right, without appeal, to dismiss any student who does not respect its
standard of conduct, education, or spirituality.


We have read the Statement of Faith. We are willing to have our child trained in accordance with it. Your typed name below will be considered your signature and acknowledgement of application.


Father's Signature

Mother's Signature



PLEASE ANSWER MATH QUIZ CORRECTLY: 12+48=?