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APPLICATION FOR ENROLLMENT
Student Information Today’s Date _____________ Grade Level Applying For: ________
Last Name: ___________________________ First Name _______________________________ Male Female Middle Name: _________________________ Nickname: _____________________________ Birth date ___/___/___ Place of Birth: ___________________________ Student’s Social Security # _________________________________ Ethnicity: African American Asian Caucasian Hispanic Native American Other _____________Denomination: _____________________________________ Church: _______________________________________ Physical Disabilities / Allergies: _____________________________________________________________________ Physicians Name ________________________________________________________Phone # __________________ Does Student have special needs? Yes No if yes, explain: ____________________________________________ Last school attended: ______________________________________________________________________________ School Address _____________________________________City /State / Zip ________________________________ Family Information (Please help us keep all your information current!) Father / Guardian Last Name: __________________ First: __________________ Middle: __________ Relationship: _______________ Address, City, State, Zip ___________________________________________________________________________ Home Phone: ___________________ Cell Phone: _______________________ Work Phone: ___________________ Occupation: _____________________ Employer: _____________________ Social Security # ___________________ E-mail Address: ____________________________________ Check all that apply: Legal custody Receives mailing Married Divorced Separated Widowed SingleMother/ Guardian Last Name: __________________ First: __________________ Middle: __________ Relationship: _______________ Address, City, State, Zip ___________________________________________________________________________ (PLEASE SEE BACK)
Home Phone: ____________________ Cell Phone: ______________________ Work Phone: ___________________ Occupation: _____________________ Employer: _____________________ Social Security # ___________________ E-mail Address: ____________________________________ Check all that apply: Legal custody Receives mailing Married Divorced Separated Widowed Single
How did you find out about CCA? ________________________________________________________ Were you referred to us by an existing CCA family? Please list: _______________________________ |
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