Student Application

1. Student Information

I am filling this form out for someone else

By checking the box above, you are indicating that the information provided in this form is for someone else (e.g. a child or spouse). To do so, you must enter your own name and e-mail address below, so that we may track who is actually submitting the form, and send e-mail notifications as needed. Note that in this case, a patient e-mail address is not required, so it does not need to be provided if the patient does not have their own.

Your First Name *

Your Last Name *

Your E-mail Address *

First Name *

Middle Name

Last Name *

Patient E-mail Address *

Gender *

Address

City

State

Postal Code

Primary Phone

Cell Phone

Employer Name

Applying for Grade

School Year

School District where child resides

Place of Birth

Ethnic Background

Church Student Attends

Denomination

Church Address

Pastor

2. Educational History

Yes

No

Has the Student repeated a grade?

If yes, what grade?

List All The Schools Previously Attended:

3. Student Behavior

What is the Student's Attitude Towards School and Teachers?

What is the Student's Attitude Towards Discipline?

Yes

No

Has the Student any history of an unusual physical or emotional conditiuon, or a learning disability which has required professional attention, or which might require special attention at Tabernacle Christian Academy?

If yes, please explain.

Please Include Copies of all Reports

4. Student Special Needs

Yes

No

Has the Student been enrolled in a special class or recieved tutoring?

If Yes, Please Explain:

Yes

No

Does Student wear glasses or corrective lenses?

Yes

No

Has the Student had a history of ear infections or hearing difficulties?

If Yes, Please Explain:

5. Check if School Personnel have reported any of the following about your child, or if you have observed these characteristics at home:

Create a password

Please use the field below to create a password for your patient record. This will allow you to save your progress and retrieve your information at later time if you cannot complete this form in one sitting. (Passwords must be at least 4 characters long.)

Password *

Confirm Password *