Date of Last Upload:
Monday, November 7, 2022
Student Enrollment Form
New Student Information
Select the Submit Application tab after you have filled in all information including students, primary and secondary family, and emergency/contacts. Use the tab buttons to select the pages to fill in the information.
*
Required fields are bold.
Student's Information
Primary Family Information
Secondary Family Information
Contact Information
Submit Application
Student 1
*
Last Name
*
First Name
Middle Name
Preferred Name
Date of Birth
1234567890qwertyuiop1234567890zxcvbnmlpo1234567890qwertyuiop0987654321qwwertyu989787665432
<None>
0123456789qwertyuiopasdfghjklzxcvbnm0p9o8i7u6y5t4r3e2w1qqawsedrftghyhujikolazsxdcfvgbhnjm
Church Affiliation
<None>
Assembly of God
Baptist
Catholic
Church of God
Episcopal
Jehovah's Witness
Jewish
Lutheran
Methodist
Muslim
Presbyterian
United Church of God
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E-Mail
*
Grade Level
<None>
Infants
Toddlers
K4
K5
1
2
3
a New Test
4
5
6
7
8
9
10's
11
12
Blood Type
<None>
A+
A-
AB+
AB-
B+
B-
O+
O-
Allergies (mm/dd/yyyy)
jdfjhasdjklhjklasdhfjklhasdjkfhjklshadfjkhjkasdhfjkhsdkjfhkjshdjkflhjkasdhfkjhsjkfhjkshdkfhkjsdfhkshadjkfhklsdhfklhskadlfhjkshadfkhjkasdfhjkhsdjkfhkasdhfjkhasdjkfhjksadhfjkhasdjkfh
Family Lifestyle
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Student 2
*
Last Name
*
First Name
Middle Name
Preferred Name
Date of Birth
1234567890qwertyuiop1234567890zxcvbnmlpo1234567890qwertyuiop0987654321qwwertyu989787665432
<None>
0123456789qwertyuiopasdfghjklzxcvbnm0p9o8i7u6y5t4r3e2w1qqawsedrftghyhujikolazsxdcfvgbhnjm
Church Affiliation
<None>
Assembly of God
Baptist
Catholic
Church of God
Episcopal
Jehovah's Witness
Jewish
Lutheran
Methodist
Muslim
Presbyterian
United Church of God
fgdfgdgdf gdfjgdjklfg djkfhgjkhd fkghkdfg kdfgkj dfkgd df df kdfk dhf gdf k ddf hdf dfg dfl dfghlgjkhdfkg dflkfdg dfkgd df df kdfk dhf gdf k ddf hdf dfg dfl dfghlgjkhdfkg dfkgd df df kdfk dhf gdf k ddf hdf dfg dfl dfghlgjkhdfkgdfkgd df df kdfk dhf gdf k ddf hdf dfg dfl dfghlgjkhdfkgdfkgd df df kdfk dhf gdf k ddf hdf dfg dfl dfghlgjkhdfkg dfkgd df df kdfk dhf gdf k ddf hdf dfg dfl dfghlgjkhdfkg
E-Mail
*
Grade Level
<None>
Infants
Toddlers
K4
K5
1
2
3
a New Test
4
5
6
7
8
9
10's
11
12
Blood Type
<None>
A+
A-
AB+
AB-
B+
B-
O+
O-
Allergies (mm/dd/yyyy)
jdfjhasdjklhjklasdhfjklhasdjkfhjklshadfjkhjkasdhfjkhsdkjfhkjshdjkflhjkasdhfkjhsjkfhjkshdkfhkjsdfhkshadjkfhklsdhfklhskadlfhjkshadfkhjkasdfhjkhsdjkfhkasdhfjkhasdjkfhjksadhfjkhasdjkfh
Family Lifestyle
fsdf sdfsdf sdf sdf sdfsdf sdfjklsdfhjksdhfkksdfhkljsdfjk lkjsdl;f sdklf fdl sjkf
Student 3
*
Last Name
*
First Name
Middle Name
Preferred Name
Date of Birth
1234567890qwertyuiop1234567890zxcvbnmlpo1234567890qwertyuiop0987654321qwwertyu989787665432
<None>
0123456789qwertyuiopasdfghjklzxcvbnm0p9o8i7u6y5t4r3e2w1qqawsedrftghyhujikolazsxdcfvgbhnjm
Church Affiliation
<None>
Assembly of God
Baptist
Catholic
Church of God
Episcopal
Jehovah's Witness
Jewish
Lutheran
Methodist
Muslim
Presbyterian
United Church of God
fgdfgdgdf gdfjgdjklfg djkfhgjkhd fkghkdfg kdfgkj dfkgd df df kdfk dhf gdf k ddf hdf dfg dfl dfghlgjkhdfkg dflkfdg dfkgd df df kdfk dhf gdf k ddf hdf dfg dfl dfghlgjkhdfkg dfkgd df df kdfk dhf gdf k ddf hdf dfg dfl dfghlgjkhdfkgdfkgd df df kdfk dhf gdf k ddf hdf dfg dfl dfghlgjkhdfkgdfkgd df df kdfk dhf gdf k ddf hdf dfg dfl dfghlgjkhdfkg dfkgd df df kdfk dhf gdf k ddf hdf dfg dfl dfghlgjkhdfkg
E-Mail
*
Grade Level
<None>
Infants
Toddlers
K4
K5
1
2
3
a New Test
4
5
6
7
8
9
10's
11
12
Blood Type
<None>
A+
A-
AB+
AB-
B+
B-
O+
O-
Allergies (mm/dd/yyyy)
jdfjhasdjklhjklasdhfjklhasdjkfhjklshadfjkhjkasdhfjkhsdkjfhkjshdjkflhjkasdhfkjhsjkfhjkshdkfhkjsdfhkshadjkfhklsdhfklhskadlfhjkshadfkhjkasdfhjkhsdjkfhkasdhfjkhasdjkfhjksadhfjkhasdjkfh
Family Lifestyle
fsdf sdfsdf sdf sdf sdfsdf sdfjklsdfhjksdhfkksdfhkljsdfjk lkjsdl;f sdklf fdl sjkf
Student 4
*
Last Name
*
First Name
Middle Name
Preferred Name
Date of Birth
1234567890qwertyuiop1234567890zxcvbnmlpo1234567890qwertyuiop0987654321qwwertyu989787665432
<None>
0123456789qwertyuiopasdfghjklzxcvbnm0p9o8i7u6y5t4r3e2w1qqawsedrftghyhujikolazsxdcfvgbhnjm
Church Affiliation
<None>
Assembly of God
Baptist
Catholic
Church of God
Episcopal
Jehovah's Witness
Jewish
Lutheran
Methodist
Muslim
Presbyterian
United Church of God
fgdfgdgdf gdfjgdjklfg djkfhgjkhd fkghkdfg kdfgkj dfkgd df df kdfk dhf gdf k ddf hdf dfg dfl dfghlgjkhdfkg dflkfdg dfkgd df df kdfk dhf gdf k ddf hdf dfg dfl dfghlgjkhdfkg dfkgd df df kdfk dhf gdf k ddf hdf dfg dfl dfghlgjkhdfkgdfkgd df df kdfk dhf gdf k ddf hdf dfg dfl dfghlgjkhdfkgdfkgd df df kdfk dhf gdf k ddf hdf dfg dfl dfghlgjkhdfkg dfkgd df df kdfk dhf gdf k ddf hdf dfg dfl dfghlgjkhdfkg
E-Mail
*
Grade Level
<None>
Infants
Toddlers
K4
K5
1
2
3
a New Test
4
5
6
7
8
9
10's
11
12
Blood Type
<None>
A+
A-
AB+
AB-
B+
B-
O+
O-
Allergies (mm/dd/yyyy)
jdfjhasdjklhjklasdhfjklhasdjkfhjklshadfjkhjkasdhfjkhsdkjfhkjshdjkflhjkasdhfkjhsjkfhjkshdkfhkjsdfhkshadjkfhklsdhfklhskadlfhjkshadfkhjkasdfhjkhsdjkfhkasdhfjkhasdjkfhjksadhfjkhasdjkfh
Family Lifestyle
fsdf sdfsdf sdf sdf sdfsdf sdfjklsdfhjksdhfkksdfhkljsdfjk lkjsdl;f sdklf fdl sjkf
Student 5
*
Last Name
*
First Name
Middle Name
Preferred Name
Date of Birth
1234567890qwertyuiop1234567890zxcvbnmlpo1234567890qwertyuiop0987654321qwwertyu989787665432
<None>
0123456789qwertyuiopasdfghjklzxcvbnm0p9o8i7u6y5t4r3e2w1qqawsedrftghyhujikolazsxdcfvgbhnjm
Church Affiliation
<None>
Assembly of God
Baptist
Catholic
Church of God
Episcopal
Jehovah's Witness
Jewish
Lutheran
Methodist
Muslim
Presbyterian
United Church of God
fgdfgdgdf gdfjgdjklfg djkfhgjkhd fkghkdfg kdfgkj dfkgd df df kdfk dhf gdf k ddf hdf dfg dfl dfghlgjkhdfkg dflkfdg dfkgd df df kdfk dhf gdf k ddf hdf dfg dfl dfghlgjkhdfkg dfkgd df df kdfk dhf gdf k ddf hdf dfg dfl dfghlgjkhdfkgdfkgd df df kdfk dhf gdf k ddf hdf dfg dfl dfghlgjkhdfkgdfkgd df df kdfk dhf gdf k ddf hdf dfg dfl dfghlgjkhdfkg dfkgd df df kdfk dhf gdf k ddf hdf dfg dfl dfghlgjkhdfkg
E-Mail
*
Grade Level
<None>
Infants
Toddlers
K4
K5
1
2
3
a New Test
4
5
6
7
8
9
10's
11
12
Blood Type
<None>
A+
A-
AB+
AB-
B+
B-
O+
O-
Allergies (mm/dd/yyyy)
jdfjhasdjklhjklasdhfjklhasdjkfhjklshadfjkhjkasdhfjkhsdkjfhkjshdjkflhjkasdhfkjhsjkfhjkshdkfhkjsdfhkshadjkfhklsdhfklhskadlfhjkshadfkhjkasdfhjkhsdjkfhkasdhfjkhasdjkfhjksadhfjkhasdjkfh
Family Lifestyle
fsdf sdfsdf sdf sdf sdfsdf sdfjklsdfhjksdhfkksdfhkljsdfjk lkjsdl;f sdklf fdl sjkf
Primary Family Information
Address Line 1
Address Line 2
City
State
ZIP Code
Home Phone
Home Listed
Cell Phone
Cell Listed
Parent 1 Information
*
Last Name
*
First Name
Middle Name
Preferred Name
Date of Birth
Marital Status
<None>
Divorced
Engaged
Married
Separated
Single
Widow
Widower
Suffix
<None>
Sr.
II
III
IV
V
VI
Jr.
Title
<None>
Dr.
Miss
Mr.
Mrs.
Ms.
Rev.
Captain
Mr
Mrs
Dr
Ms
Church Affiliation
<None>
Assembly of God
Baptist
Catholic
Church of God
Episcopal
Jehovah's Witness
Jewish
Lutheran
Methodist
Muslim
Presbyterian
United Church of God
Gender
<None>
Female
Male
Race
<None>
African American
Asian
Caucasian
Hispanic
Native American
Home E-Mail
Cell Phone
Cell Listed
Company Name
Business Phone
Extension
Job Title
Is Emergency Contact
Business E-Mail
Is Allowed to Pickup
Parent 2 Information
*
Last Name
*
First Name
Middle Name
Preferred Name
Date of Birth
Marital Status
<None>
Divorced
Engaged
Married
Separated
Single
Widow
Widower
Suffix
<None>
Sr.
II
III
IV
V
VI
Jr.
Title
<None>
Dr.
Miss
Mr.
Mrs.
Ms.
Rev.
Captain
Mr
Mrs
Dr
Ms
Church Affiliation
<None>
Assembly of God
Baptist
Catholic
Church of God
Episcopal
Jehovah's Witness
Jewish
Lutheran
Methodist
Muslim
Presbyterian
United Church of God
Gender
<None>
Female
Male
Race
<None>
African American
Asian
Caucasian
Hispanic
Native American
Home E-Mail
Cell Phone
Cell Listed
Company Name
Business Phone
Extension
Job Title
Is Emergency Contact
Business E-Mail
Is Allowed to Pickup
Secondary Family Information
Address Line 1
Address Line 2
City
State
ZIP Code
Home Phone
Home Listed
Cell Phone
Cell Listed
Parent 3 Information
*
Last Name
*
First Name
Middle Name
Preferred Name
Date of Birth
Marital Status
<None>
Divorced
Engaged
Married
Separated
Single
Widow
Widower
Suffix
<None>
Sr.
II
III
IV
V
VI
Jr.
Title
<None>
Dr.
Miss
Mr.
Mrs.
Ms.
Rev.
Captain
Mr
Mrs
Dr
Ms
Church Affiliation
<None>
Assembly of God
Baptist
Catholic
Church of God
Episcopal
Jehovah's Witness
Jewish
Lutheran
Methodist
Muslim
Presbyterian
United Church of God
Gender
<None>
Female
Male
Race
<None>
African American
Asian
Caucasian
Hispanic
Native American
Home E-Mail
Cell Phone
Cell Listed
Company Name
Business Phone
Extension
Job Title
Is Emergency Contact
Business E-Mail
Is Allowed to Pickup
Parent 4 Information
*
Last Name
*
First Name
Middle Name
Preferred Name
Date of Birth
Marital Status
<None>
Divorced
Engaged
Married
Separated
Single
Widow
Widower
Suffix
<None>
Sr.
II
III
IV
V
VI
Jr.
Title
<None>
Dr.
Miss
Mr.
Mrs.
Ms.
Rev.
Captain
Mr
Mrs
Dr
Ms
Church Affiliation
<None>
Assembly of God
Baptist
Catholic
Church of God
Episcopal
Jehovah's Witness
Jewish
Lutheran
Methodist
Muslim
Presbyterian
United Church of God
Gender
<None>
Female
Male
Race
<None>
African American
Asian
Caucasian
Hispanic
Native American
Home E-Mail
Cell Phone
Cell Listed
Company Name
Business Phone
Extension
Job Title
Is Emergency Contact
Business E-Mail
Is Allowed to Pickup
Contact Information (Other than parents)
Contact 1
*
Last Name
*
First Name
Relation
<None>
Aunt
Friend
Grandparent
Spouse
Brother
FATHER
Mother
Uncle
Sister
test
GrandChild
newfff
haha
Is Emergency Contact
Home Phone
Is Allowed to Pickup
Business Phone
Pickup License
Mobile Phone
Pickup Tag
Pickup Notes
Contact 2
*
Last Name
*
First Name
Relation
<None>
Aunt
Friend
Grandparent
Spouse
Brother
FATHER
Mother
Uncle
Sister
test
GrandChild
newfff
haha
Is Emergency Contact
Home Phone
Is Allowed to Pickup
Business Phone
Pickup License
Mobile Phone
Pickup Tag
Pickup Notes
Contact 3
*
Last Name
*
First Name
Relation
<None>
Aunt
Friend
Grandparent
Spouse
Brother
FATHER
Mother
Uncle
Sister
test
GrandChild
newfff
haha
Is Emergency Contact
Home Phone
Is Allowed to Pickup
Business Phone
Pickup License
Mobile Phone
Pickup Tag
Pickup Notes
Medical Contacts
Physician
Physician Phone Number
Dentist
Dentist Phone Number
Hospital
Hospital Phone Number
Insurance
Insurance Phone Number
Policy Number
Finished
Confirmation E-Mail address:
Please press the save button to submit the new student application.
