Today's Date:



STUDENT INFORMATION:
Student Name

Current Street Address

City

State

Zip

Home Phone

Student Birthplace

Date of Birth



School District

Student Age

Student Sex
MaleFemale
Relation Status
Natural ChildAdopted Child


PROGRAM INFORMATION:
Program Desired (select): K3 and up have to be 100% potty- trained (less than 3 accidents in a
semester & able to change themselves, able to pull up / down clothing, get on/off the potty,
wipe themselves, & wash hands) Elastic waist would need to be worn if child cannot zip/button
on own.
K3-half day (3 day)K3-half day (5 day)K3-full day (3 day)K3- full day (5 day)K4- five day (half day)K4- five day (full day)
Additional options:
A.M. DaycareExtended Daycare


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 Phone

Please list any special health concerns:



CHURCH AFFILIATION:
Name of Church

Name of Pastor

Church Address

Church Phone

ADDITIONAL STUDENT INFORMATION:
List any brothers or sisters along with additional info in the household:
Brothers or Sisters / Age / Grades / School attending (example: Johnny / 12yrs old / 6th grade / Middle School):



Student's Previous School(s)

Reason for leaving

Students Strengths

Students Weaknesses

List student's special abilities, interests, or hobbies:

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. Our child may go on scheduled field trips and other school activities.
2. The teacher has full discretion in the discipline of my child.
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=?