<p> HORIZON CHRISTIAN ACADEMY</p><p>Enrollment Form</p><p>Applying for Grade ______School year applying for ______</p><p>Campus applying for _____Broadway _____Coliseum _____Wells St. </p><p>Student’s Legal Name ______First Middle Last</p><p>Student’s Date of birth ______</p><p>Who does student live with ______</p><p>Who is student’s legal guardian(s) ______</p><p>PARENT INFORMATION</p><p>Father’s Name ______First Middle Last Father’s Address ______</p><p>______</p><p>Father’s place of employment: ______</p><p>Father’s phone numbers ______Home Cellular Work Father’s email: ______</p><p>Mother’s Name ______First Middle Last</p><p>Mother’s Address (if different from father) ______</p><p>______</p><p>Mother’s place of employment ______</p><p>Mother’s phone numbers ______Home Cellular Work</p><p>Mother’s email ______Parents are: ____Married ____Divorced ____Separated ____Deceased____Single</p><p>Student lives with ____Both parents ____Mother ____Father ____Legal Guardian</p><p>If parents are separated or divorced, who has legal custody of child(ren) ______</p><p>Emergency Contact Name (other than person the child resides with) </p><p>______</p><p>Emergency Contact Number (other than the person the child resides with) </p><p>______</p><p>Family’s church home: ______</p><p>Physician’s Name: ______Physician’s Number: ______</p><p>In the event of a medical emergency which hospital would be your first choice: </p><p>______</p><p>STUDENT INFORMATION</p><p>Has student ever been suspended or expelled from school? ______</p><p>If yes, please explain: ______</p><p>______</p><p>Has student ever been in any legal trouble? ______</p><p>If yes, please explain: ______</p><p>______</p><p>Does student have an IEP? ______If yes, please provide a copy</p><p>Please list student’s interests, hobbies, talents ______</p><p>______</p><p>Please list any allergies child has: ______Please list any medical issues child has:______</p><p>Please list any medications child takes: ______</p><p>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.</p><p>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:</p><p>______Asian or Asian American ______Hispanic</p><p>______Black or African American ______Bi-racial</p><p>______Caucasian ______Other </p><p>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. </p><p>______Parent/Guardian Signature Date </p><p>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.</p>