Get documents about "Agape Christian high school
Document Sample
Agape Christian high school
Southern Illinois’ Regional Christian School
(An independent Christian interdenominational not-for-profit school)
PO Box 790 ** Energy, IL 62933 ** (618) 942-4300
Application for Admission
Today’s date: _____________
Student Information
*If your family is enrolling more than one student, please complete a separate application for each student.
Grade to Enter: (circle one)___9______10________11_______12______
Student’s Name: ____________________________________________ Home phone #______________
Last First Middle Nickname
Street Address: ________________________________ City or Township _________________Zip____
Cell phone #’s: Student’s________________ Mother’s________________ Father’s________________
Date of Birth:_________ Birthplace: City______________State___ Student Soc. Secur.#_____________
Please supply the school office with a copy of birth certificate and immunization records
Gender and Age: Female ___ Male ___ Current age ____
Family Information
Student lives with: ___Father/Mother ___Mother ___Father
___StepMother/Father ___StepFather/Mother ___Guardian
Father’s Name _______________________ Mother’s Name _____________________________
Address and home phone(if different than Address and home phone (if different than student or
student or mother)______________________ father) _____________________________________
________________________cell # _________ ___________________________cell # ___________
Occupation: ____________________________ Occupation: ________________________________
Employer: _____________________________ Employer: _________________________________
Business phone: _________________________ Business phone: _____________________________
Marital status: __________________________ Marital status: ______________________________
Family e-mail address: ___________________
(If student lives with a guardian, list name and address:_______________________________________)
Emergency Information (in case parents cannot be contacted immediately)
_______________________________ ________________ ___________________________________
(name) (phone #) (relationship to student)
ACHS admits ninth through twelfth grade without regard to race, color, national or ethnic origin.
Additional Student Information:
Has student repeated any grade? ___Yes ___No
If Yes, why? _________________________________________________________________________
Has student had any major discipline problems in school? ___Yes ___No
If yes, please explain briefly: ____________________________________________________________
____________________________________________________________________________________
Has student ever been dismissed, suspended or asked to withdraw from any school? ___Yes ___No
If yes, please explain on a separate sheet and attach to this application.
School applicant last attended: ____________________________ Grade level______
Address of previous school [if other than Grace/Johnston City, Heartland/Harrisburg,
MCA/Murphysboro, or Unity/Herrin-Marion]: ______________________________________________
City: _______________________________ State: _________________ Phone #: ________________
Are there any unusual factors in the student’s life of which teacher(s) or staff should be aware? (adoption,
accident or serious injury, recent divorce, recent family deaths, etc.) If yes, please explain as detailed as
you wish: ____________________________________________________________________________
______________________________________________________ (add extra lines on back if necessary)
Does the student have any physical, emotional, or mental disabilities in addition to the above which
would be helpful for faculty and/or staff to be aware? _________________________________________
Briefly describe the student’s extracurricular interests and activities (including sports): ______________
____________________________________________________________________________________.
Additional Family Information:
Family Physician (include name, address, phone): ____________________________________________
What is the name of your family church? ___________________________________________________
Pastor’s name: ________________________________
What is your normal attendance and participation pattern? ___ weekly ___ about twice a month
___seldom ___ attend occasionally but not actively participating ___do not attend or participate
What members of your family are professing Christians and what members, if any, are not? (Please
include all family members of the household including small children) ___________________________
____________________________________________________________________________________.
Briefly, why have you chosen a Christian high school for your child’s education? ___________________
_____________________________________________________________________________________
Parent/Student Covenant with ACHS
We (parents) and I (student) understand and covenant that this student’s attendance at ACHS
signifies that we collectively pledge to agreeably abide by all policies, requirements and rules set
forth by the school as of now and hereafter to be set by school board or administration policy.
____________________________ _____ _______________________________ _________
Parent’s signatures Date Student’s signature Date
2
Related docs
