EmailMe Form - SURGE CHRISTIAN ACADEMY ENROLLMENT APPLICATION

I. STUDENT INFORMATION

Directions: Please complete each field.

Grade Level Applying For

Student Name

First Middle Last

Gender

Date of Birth

MM / DD / YYYY

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Home Phone

### - ### - ####

Cell Phone

### - ### - ####

Student Email

II. PARENT (Primary Caregiver) INFORMATION

Directions: Please complete each field.

Parent Name (Primary Caregiver)

First Middle Last

Relationship

Other

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Home Phone

### - ### - ####

Cell Phone

### - ### - ####

Work Phone

### - ### - ####

Parent Email

III. SCHOOL (ACADEMIC) INFORMATION

Directions: Please complete each field.

Previous School Attended

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

School Phone

### - ### - ####

School Fax

### - ### - ####

School Email

Parent (Primary Caregiver) Signature

Student Signature

Date Time

MM / DD / YYYY

IV. ATHLETIC INFORMATION

Directions: Please complete each field.

Athletic Interest - 1st Choice

Athletic Interest - 2nd Choice

Athletic Interest - 3rd Choice

File Upload - Scanned Documents
Birth Certificate - Health Record - Immunization Record - Letter of Recommendation - Report Cards - Standardized Testing - Transcript