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MILLENNIAL CHRISTIAN SCHOOL STUDENT ENROLLMENT FORM
FAMILY INFORMATION
Father Mother
______________________________________________ _____________________________________________________ Last First M Last First M
Employer ______________________________________ Employer _____________________________________________
Occupation ________________________ ___________ Occupation ______________________________ ____________ Work Phone Work Phone ______________ ___________________ _______________ ____________________ Cell Phone Date of Birth Cell Phone Date of Birth
Social Security Number ___________________________ Social Security Number __________________________________
Driver’s License Number __________________________ Driver’s License Number _________________________________
______________ _______________________________________ _________________________ _______ ___________ Home Phone Address City State Zip
Email Address ______________________________________________
Grandparent Information
The school would like to send notices to your child’s grandparents about Grandparents’ Day and other special events. Please include the name and addresses of the grandparents.
Name ______________________________ ___________ Name __________________________________ ____________ Phone Phone
Address _________________________________________ Address _______________________________________________
City _______________________ State _______ Zip ______ City __________________________ State ________ Zip _______
Church Background Information
Church you now attend _____________________________________________________
Please circle the appropriate response for the questions below:
Marital Status: Single / Married
Religious affiliation:
Assembly of God Church of God Church of Christ Muslim Pentecostal Baptist Congregational Lutheran Nazarene Presbyterian Catholic Episcopal Mormon Jewish Seventh Day Adventist Christian Science Hindu Methodist Nondenominational None Other _____________ How often do you attend?
Weekly Monthly Occasionally Seldom Never
STUDENT INFORMATION
__________________________________________________ ____________________ ____________________ Last First M Social Security Number Date of Birth
Gender: Male / Female Date Enrolled ____/____/____ ______________________ Place of Birth Application for (circle one)
K (half day) 5th grade K (full day) 6th grade 1st grade 7th grade 2nd grade 8th grade 3rd grade 9th grade 4th grade 10th grade
I am interested in information about your after school program for my child Yes ____ No ____
School last attended and address ______________________________________________________________________________
If parents are separated, with whom does the child reside? __________________________________________________________ Name Address Phone
EMERGENCY INFORMATION
IN AN EMERGENCY WHEN A PARENT CANNOT BE REACHED, PLEASE CONTACT:
Relationship Name Home Phone Work Phone
____________________ _______________________________ ________________________ ______________________
____________________ _______________________________ ________________________ ______________________
Please keep the daytime, home and emergency contact numbers for parents / guardians up-to-date.
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