Apply - Bethel Christian Academy

Student Details

First Name

Middle Name

Last Name

Preferred Name

Social Security #

Birth Date

Birth Place

Age

Sex

Male Female

Race

White Black Hispanic Other

Contact Informaiton

Street Address

City

State

Zip

Home Phone

Cell Phone

Academic History

Name/Address of Last School Attended

Last Grade Attended

Grade Applying For

Has student ever repeated grades, been dismissed or suspended at any school?

Yes No

If yes to above, please provide brief description of circumstances.

Family Information

Does the student live with both parents?

Yes No

If no to above, please check one of the following.

Mother Only Father Only Other

Father’s Information

Father’s Name

Father’s Place of Employment

Father’s Work Phone

Father’s Academic Level

Mother’s Information

Mother’s Name

Mother’s Place of Employment

Mother’s Work Phone

Mother’s Academic Level

Guardian/Stepparent’s Information

Guardian’s Name

Guardian’s Place of Employment

Guardian’s Work Phone

Guardian’s Academic Level

Grandparent’s Information

1st Grandparent Name

1st Grandparent Address

2nd Grandparent Name

2nd Grandparent Address

Sibling Information (Siblings Attending BCA Only)

1st Sibling Name

1st Sibling Grade

2nd Sibling Name

2nd Sibling Grade

3rd Sibling Name

3rd Sibling Grade

Parent/Guardian Signatures

By signing below, I certify that the information provided in this application is true and accurate to the best of my knowledge. Furthermore, I understand that it is my responsibility to immediately notify the administrative office of BCA if any changes to the information represented in this application occur.

Signature of Parent/Guardian #1

Signature of Parent/Guardian #2

Date

Student Information

Family Information

Medical Information

Sign & Submit

Student Details

First Name

Middle Name

Last Name

Preferred Name

Social Security #

Birth Date

Birth Place

Age

Sex

Race

Contact Informaiton

Street Address

City

State

Zip

Home Phone

Cell Phone

Academic History

Name/Address of Last School Attended

Last Grade Attended

Grade Applying For

Has student ever repeated grades, been dismissed or suspended at any school?

If yes to above, please provide brief description of circumstances.

Family Information

Does the student live with both parents?

If no to above, please check one of the following.

Father’s Information

Father’s Name

Father’s Place of Employment

Father’s Work Phone

Father’s Academic Level

Mother’s Information

Mother’s Name

Mother’s Place of Employment

Mother’s Work Phone

Mother’s Academic Level

Guardian/Stepparent’s Information

Guardian’s Name

Guardian’s Place of Employment

Guardian’s Work Phone

Guardian’s Academic Level

Grandparent’s Information

1st Grandparent Name

1st Grandparent Address

2nd Grandparent Name

2nd Grandparent Address

Sibling Information (Siblings Attending BCA Only)

1st Sibling Name

1st Sibling Grade

2nd Sibling Name

2nd Sibling Grade

3rd Sibling Name

3rd Sibling Grade

Medical Information

Does this student have a physical disability or handicap?

If yes to above, please provide brief description of the physical disability or handicap.

May this student be given a non-aspirin pain reliever such as Tylenol or Ibuprofen?

Health Questionnaire

Does your child have an unusual health conditions?

Check any health conditions that apply to your child…

If Other checked above, please provide brief description of the condition.

Insurance Information

Insurance Company

Policy Number

Insured’s Name

ID Number

Family Physician

Family Physician’s Name

Office Phone

Family Dentist

Family Dentist’s Name

Office Phone

Emergency Treatment & HIPAA Release

Parent/Guardian Signatures

Signature of Parent/Guardian #1