MSMBC Christian Academy Initial application – Mt. Sinai Missionary Baptist Church

MSMBC Christian Academy Student (Initial) Application Form

Full Name

Date of Birth

Age

Gender

Grade Applying for

Current/Previous School

Home Address

City

State

Zip code

Student's church affiliation

Has the student made a personal commitment to Christ?

Yes No Unsure

Brief Testimony (optional)

Parent /Guardian (1) Name

Relationship to Student

Phone Number

Parent /Guardian (2) Name

Relationship to Student

Phone Number

Church Home

Are you member?

Yes No

Does Your Family Attend Regularly?

Yes No

Has Your Child ever been suspended?

Has Your Child ever been expelled?

Has an IEP or a 504 Plan

If yes please explain

Any Know Allergies or Medical Conditions

Medications currently taking

Emergency Contact Name (other than parent)

Emergency Contact Phone Number (other than parent)

Consent/Signature

I/we affirm that the information provided is true and complete. We understand that the Christian Academy integrates biblical principles into its academic program and agree to support the school's mission, values and policies.

Parent/Gardian Signature

Date

Parent/Gardian Signature

Date