Application

Please print clearly in blue or black ink.

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:________________________________________________

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)____________________________________________