Horizon Christian Academy

HORIZON CHRISTIAN ACADEMY

Enrollment Form

Applying for Grade ______School year applying for ______

Campus applying for _____Broadway _____Coliseum _____Wells St.

Student’s Legal Name ______First Middle Last

Student’s Date of birth ______

Who does student live with ______

Who is student’s legal guardian(s) ______

PARENT INFORMATION

Father’s Name ______First Middle Last Father’s Address ______

______

Father’s place of employment: ______

Father’s phone numbers ______Home Cellular Work Father’s email: ______

Mother’s Name ______First Middle Last

Mother’s Address (if different from father) ______

______

Mother’s place of employment ______

Mother’s phone numbers ______Home Cellular Work

Mother’s email ______Parents are: ____Married ____Divorced ____Separated ____Deceased____Single

Student lives with ____Both parents ____Mother ____Father ____Legal Guardian

If parents are separated or divorced, who has legal custody of child(ren) ______

Emergency Contact Name (other than person the child resides with)

______

Emergency Contact Number (other than the person the child resides with)

______

Family’s church home: ______

Physician’s Name: ______Physician’s Number: ______

In the event of a medical emergency which hospital would be your first choice:

______

STUDENT INFORMATION

Has student ever been suspended or expelled from school? ______

If yes, please explain: ______

______

Has student ever been in any legal trouble? ______

If yes, please explain: ______

______

Does student have an IEP? ______If yes, please provide a copy

Please list student’s interests, hobbies, talents ______

______

Please list any allergies child has: ______Please list any medical issues child has:______

Please list any medications child takes: ______

Please list any additional information that may assist our Guidance Department. Examples (fears child may have, family issues that child may be dealing with that may effect his/her demeanor at school, recent death of a loved one, recent move, etc.

Horizon Christian Academy will keep records regarding the racial composition of its Student Body for reporting purposes. Please record your child’s racial ethnicity below:

______Asian or Asian American ______Hispanic

______Black or African American ______Bi-racial

______Caucasian ______Other

Upon applying for enrollment at Horizon Christian Academy it is agreed that the parent(s) and student will adhere to the guidelines set forth in the Horizon Christian Academy Student Handbook and the Horizon Christian Academy Financial Agreement. The signature below indicates agreement to comply with the policies set forth by Horizon Christian Academy.

______Parent/Guardian Signature Date

Horizon Christian Academy admits students of any race, color, national and ethnic origin to all the rights, privileges, programs, and activities generally accorded or made available to students at the school. Horizon Christian Academy does not discriminate on the basis of race, color, national and ethnic origin in administration of its educational policies, admissions policies, scholarship and loan programs, and athletic and other school-administered programs.