Application Form 
          Please print clearly in blue or black ink

                                                           
                                                                                Office use
                                                                              Enrollment fees pd.
                                                                               _________
                                                                             

Child Full Name__________________________________________________

Nickname___________________ Date of Birth__/__/__ Gender ____________

Address_________________________ Home Phone (      ) _______________

City_______________________________ State____ Zip Code ____________

Mother’s Full Name_____________________ Home Phone (      )___________

Address__________________________________

City________________________________ State____ Zip Code____________

Occupation__________________________ Work Phone (      ) _____________

Name of Employer _______________________Cell Phone ________________

Business Address ____________________________ City ___________________

Work Hours ________________________ Driver’s License Number __________

E-Mail Address___________________________________________________

Father’s Full Name_____________________ Home Phone (      )____________

Address__________________________________

City________________________________State____ Zip Code_____________

Occupation__________________________ Work Phone (      ) ______________

Name of Employer _______________________ Cell Phone ________________

Business Address ____________________________ City _________________

Work Hours ________________________ Driver’s License Number ________

E-Mail Address___________________________________________________

Parents are: 

___ Married 

___ Living Together   

___ Divorced

___ Separated

___ Widowed

___ Single

If divorced which parent or guardian has legal custody ____________________

Other Household Members:

Name ______________________________ Age ____ Relationship __________

Name ______________________________ Age ____ Relationship __________

Name ______________________________ Age ____ Relationship __________

Name ______________________________ Age ____ Relationship __________

Known Allergies or Medical Conditions:
________________________________________________

Is there anything you would like us to know about your child?  If so,  please tell us:_________________________________

 Enrollment for Preschool /MDO_____________  Days attending Tues./ Thurs.or Tues./Thurs/Fri.___________ 
Enrollment for Homeschool Co-op____________Classes enrolling in______________________________________________________________

I understand that this is a legal binding contract, and that I am responsible for payment for my child while he or she attends Christian Life School.  

Parent/Guardian (Mother)____________________________________________

Parent/Guardian (Father)____________________________________________