WMCS STUDENT APPLICATION 2012-2013

Our Mission:
Excellence in education in a safe, positive, Christian environment
To be like Jesus as described in Luke 2:52
And Jesus increased in wisdom, stature, and in favor with God and man.
(Intellectually, physically, spiritually, and socially)
GENERAL INFORMATION
Students Name _____________________________________________________________________
Last
First
Middle
Goes By
Male

Female Age_____ as of September 1st Fall 2012 Grade Level ______________

Date of Birth___________Birthplace____________

Current Address_______________________________________________________________________
Street
City/State/Zip
Ethnicity of Student
Anglo-Saxon
Asian/Pacific Islander
Students Social Security Number _______________________
African American
Students Cell Phone Number __________________________
Hispanic
School Attending or Last Attended ______________________
Indian (American/Alaskan)
Address ______________________
Students School District ______________________
*Updating information such as change in phone #, address, & email is very important. Update forms are
available in the front office. You may also update contact information on Jupitergrades.
Fathers Name ___________________________

Mothers Name___________________________

Cell Number_____________________________

Cell Number _____________________________

Fathers Email ___________________________

Mothers E-mail___________________________

Address ________________________________

Address ________________________________

Place of Employment ______________________

Place of Employment _____________________

Occupation___________Phone _____________

Occupation _____________Phone___________

Highest grade completed __________________

Highest grade completed ___________________

Does student live at home?

Yes
Does student live with both parents?

No If not, where? ________________

Yes
No

Note: Parents seeking to limit the right of another parent to school-related information or to pick up a child or visit
with a child or remove a child MUST present the school with current and valid orders. Please check all that apply
a copy of such orders must be on file in the office:
Court Orders
Restraining Orders
Custody Orders
Modifications
No Legal Documents
Has your child previously attended WMCS?

Yes or

No If yes, what year and grade? _________

Please list other adults and children living in the household and indicate the relationship to the enrolling student.
(Please list the ages next to children aged under 18 years old)
_____________________________________________________________________________________
Are any of these children currently enrolled at WMCS? Yes or No

MEDICAL INFORMATION (Please check any of the following conditions that apply to your child.)
______ Convulsive Disorder ______ Diabetes
_______ Visual Problem ______ Hearing Problem
______ Orthopedic Disability ______Heart Problem _______ Asthma
______ Attention Deficit Disorder
Additional health problems or comments:
___________________________________________________________________________
My child is allergic to ___________________________________________________________________
What type of reaction?____________________________________________________________
Does your child take medication on a regular basis?
Yes
No
If yes, explain ________________________________________________________________________________

ACADEMIC AND BEHAVIORAL INFORMATION

Has your child been served by any of the following programs?
Speech and Hearing
Yes
No
Has your child ever received any special help or tutoring
Gifted and Talented
Yes
No
in reading? Yes
No
Counseling
Yes
No
in science? Yes
No
Adaptive P.E.
Yes
No
or math?
Yes
No
Dyslexia Program
Yes
No
Behavioral Difficulties
Yes
No Has your child ever been sent to an administrator's office for discipline?
Special Education
Yes
No
Yes
No
If yes, how many times?___________
Has your child ever been in school suspended?
Yes
No
Has your child ever been off campus suspended? Yes
No
Has your child ever been expelled from school?
Yes
No
Has your child ever been diagnosed with ADD or ADHD?
If so, please provide the doctor's diagnosis for our files.
Has your child ever been retained?

Yes

No

Yes

No

If yes, what grade level? ________

How many days has your child been absent this school year?______
______________

Reasons for absences:

Study Habits (Please check those that apply to your child)

Completes assignments on time
Self motivated
Completes assignment most of the time
Requires occasional prodding
Requires constant supervision
Requires tutoring

PARENT QUESTIONS AND TESTIMONY

What is your church affiliation?_____________________________ Name of your church: ____________________
Are you presently a member in good standing in your church?
Yes
No
Will you commit to the following:
To attend parent/teacher meetings?
To participate in fund-raising activities?
To assure that your child completes homework and home projects?
To support the faculty and students at WMCS?

Yes
Yes
Yes
Yes

No
No
No
No

Please describe the personality of your child.

____________________________________________________________________________________________
____________________________________________________________________________________________

Please make a full statement as to why you want to enroll your child at WMCS.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Please share how you integrate your faith in your family.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

STUDENT QUESTIONS (Grades 5-12)

Does the student currently (or in the past) use tobacco products?
Yes
No
If yes, explain
__________________________________________________________________________________________
Does the student currently (or in the past) drink alcoholic beverages?
Yes
No
If yes, explain
__________________________________________________________________________________________
Has the student ever been involved with drugs?
Yes
No
If yes, explain
__________________________________________________________________________________________
Has the student ever been in trouble with the law?
Yes
No
If yes, explain
__________________________________________________________________________________________
Please list the student's educational and vocational goals. (Grades 9-12)
__________________________________________________________________________________________
__________________________________________________________________________________________

FINANCIAL INFORMATION
Name of Responsible Party for tuition____________________________________________________________
Full Name
Relation to Student
Address ___________________________________________________________________________________
Street
City
State/Zip
Phone ____________________________________________________________________________________
Home
Work
Cell

A registration fee of ______________ is due upon submitting this application.

WMCS utilizes the services of SMART TUITION (www.smarttuition.com) to bill and collect tuition and fees. Upon
acceptance into WMCS, every family must set up their account with SMART TUITION. The fee to set up is $45 and
will be waived if a family pays in advance for one year.
How did you find out about WMCS?
Referred by WMCS Family Whom may we thank for their referral? _______________________
Attended WMCS - Which years? Did you graduate from WMCS? If so, what year? ___________
Local Realtor Realtors Name _______________________________
Internet Advertising
Chamber of Commerce
Newspaper Articles
Other

STATEMENT OF COOPERATION AND PERMISSION TO DISCIPLINE

In making application for my child, I give permission for my child to take part in all school activities including
counseling, sports, and school sponsored trips away from the school premises. I also give permission to the school
to administer emergency first aid and to arrange for necessary emergency medical care in the event I am not
immediately available.
If my childs behavior violates established school rules and procedures and it is necessary to take corrective action,
I give my permission to the teacher and/or administrator to use the discipline procedures stated in the WMCS
Parent/Student Handbook. I also understand that my child may be administratively withdrawn from school at the
discretion of the administration for behavior issues.
___________________________________________
Fathers Signature
Date

__________________________________________
Mothers Signature
Date

___________________________________________
Students Signature
Date

Nondiscrimination Statement:
West Memphis Christian School admits students of any race, color, national and ethnic origin to
all the rights, privileges, programs, and activities generally accorded or made available to
students at the school. It does not discriminate on the basis of race, color, national and ethnic
origin in administration or its educational policies, admissions policies, scholarship programs,
and athletic and other school-administered programs.

I certify that, to the best of my knowledge, the information contained in this application is true, accurate, and
complete:
_________________________________________
Signed

____________
Date

OFFICE USE
Date Received:

Application Fee Paid: $

Check #

Date:____________