Life Christian Academy

LIFE CHRISTIAN ACADEMY

REGISTRATION APPLICATION

Date______________

STUDENT FULL NAME ___________________________________________

Address ______________________________________________________

             City _____________________ State_____________ Zip ________

Phone _________________________ Social Security Number ___________

Age ______________ Birthdate _______________________

Grade _____________ Male/Female _______________ Race ___________

Mother’s Name ________________________________________________

Address ______________________________________________________

Employer __________________________ Phone _____________________

Social Security Number _____________________

Phone ______________________ Cellular Phone _____________________

Father’s Name _________________________________________________

Address ______________________________________________________

Employer __________________________ Phone _____________________

Social Security Number _____________________

Phone ______________________ Cellular Phone _____________________

Person to contact in case of Emergency:

_____________________________________ Phone __________________

_____________________________________ Phone __________________