APPLING CHRISTIAN ACADEMY

www.applingchristian.com

1479 Hatch Parkway South                                                                                                                (912) 367-3004

Baxley, GA 31513                              EMAIL: applingchristian@bellsouth.net              (912) 367-0076 {FAX}

2011-2012 APPLICATION FOR STUDENT ENROLLMENT

Student’s full name ________________________________________              _______________________Grade _______

Name preferred___________________________________________

Student’s address____________________________________ City______________ ST _____ Zip__________________

Parent’s email address__________________________________________________________________________

Student’s D.O.B. ___/____ /_______ Sex ___ SSN__________________ Home Telephone ______________________

Has student repeated a grade? ______If yes, explain ______________________________________________________

School previously attended _________________________________ Dates _________________________

If applicant is a new student, how did you learn about the school? ___________________________________________

Has applicant ever had any discipline/emotional/social problems in school? If yes, explain______________

______________________________________________________________________________________

Has applicant ever been suspended or expelled? _____ Has applicant ever used alcohol, drugs, or tobacco? ______

Does the applicant have any handicaps that may affect his/her progress? _____  If yes, explain _______________

________________________________________________________________________________________

Church affiliation: Name of Church __________________________________ Pastor ________________________

     Church address _________________________________________________________________

Check as it applies: member _____            attends regularly _______                  attends occasionally _________

PLEASE READ BEFORE SIGNING

I hereby authorize Appling Christian Academy to give and/or obtain emergency medical assistance for my child in the event

that I can not be reached. I assume full financial responsibility for any such medical service rendered. I acknowledge it is my

responsibility to abide by the school policies as outlined in the parent/student handbook, and to support the staff and the

administration. I acknowledge that the school board is the governing authority of the school. I acknowledge that it is my

responsibility to pay the tuition and all other fees on time as stated in the school financial policy.  Appling Christian Academy

admits students of any race, color, and national or ethnic origin.

REGISTRATION FEE IS NON-REFUNDABLE

Parent or Legal Guardian’s signature ____________________________________________________

Date _____________________________________________

Both sides of the application must be completed before the application will be accepted.

MEDICAL AND RELEASE INFORMATION

Student’s name__________________________________________________________ Grade _________

Allergies or other medical limitations________________________________________________________

Family Physician__________________________________ City____________ Telephone______________

May school personnel administer the following to your child:

__ Tylenol __Motrin __ Pepto-Bismol __Tums __Benadryl __ Dimetapp __ Cough drops __ Sore throat drops

Parent or Legal Guardian’s signature__________________________________ Date________________

Parental Status:  __ Married __ Separated __ Divorced __ Father deceased __ Mother deceased

Student lives with______________________________________________________________________

Parent’s email address__________________________________________________________________

Father’s name _____________________________________ Employer________________ WK #___________

Home # ___________________________ Mobile #______________________________

Mother’s name ____________________________________ Employer________________ WK#____________

Home # ___________________________ Mobile #_______________________________

Guardian’s name____________________________________ Employer_______________ WK #____________

Home # ____________________________________ Mobile #____________________________

Persons your child may be released to other than those listed above:

Name _________________________________ Relationship_____________ Telephone ___________________

Name _________________________________ Relationship ____________  Telephone ___________________

Name _________________________________ Relationship ____________  Telephone ___________________

Name _________________________________ Relationship _____________Telephone __________________

Name _________________________________ Relationship _____________Telephone __________________

Please state any special release circumstances regarding your child__________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________