HERBERT ARMSTRONG PREPARATORY

CHRISTIAN SCHOOL
1000 N. Federal Hwy. #333
Hollywood, FL 33023
954-555-1212

2016/2017
Enrollment Form
Student Information
Students Legal Name________________________________________________
Last

first

_____________________

Middle Initial

Preferred Name

Address___________________________________________________________________________________
Street

City

Zip

Home Phone (_____)______________________ Email____________________________ Sex _Male_Female

Grade _____Date of Birth________________ Age __________ Social Security Number___________________
Is the student a United States Citizen? yes _____ No _____

Scholarship: McKay_____ CTC ______

How did you hear about us?___________________________________________________________________

Family Information
Father/Guardian Name_______________________________________ Home Phone (_____)______________
Employer______________________________________________________ Date of Birth_________________
Social Security #________________________ Work Phone (____)___________ Cell/Pager (____)_________
Home Address (if other than students)__________________________________________________________
Mother/Guardian Name______________________________________ Home Phone (____)________________
Employer_____________________________________________________ Date of Birth ________________
Social Security #________________________ Work Phone (____)___________ Cell/Pager (____)_________
Home Address(if other than students) __________________________________________________________

Family/Marital relationships (check all that apply): Natural Parents are:

__ Together at home __Separated __ Legally Divorced __Natural Mother deceased __ Natural Father deceased
If parents are divorced or separated, who has legal custody of the child? ________________________________
Is either parent forbidden by court order from having equal access to the child or the school records? _________
(Attach a copy of court documents.)

Academic/School History
School presently attending or last attended___________________________________ Phone (____)_________
__________________________________________________________________________________________
Street Address

City

State

Zip

Reason for changing schools__________________________________________________________________

Has student ever repeated a grade? ___ Yes ___ No If yes, state grade and date. _______________________
Has student ever failed an academic subject? ___ Yes ___ No If yes, state subject ______________________
Has student ever been tested for or enrolled in a special program? (gifted, learning disabled, special needs) ____
__________________________________________________________________________________________
Has student ever been expelled, dismissed, suspended, or refused admission to another school? _____________
If yes, explain ______________________________________________________________________________
Has student ever had disciplinary difficulty at school? ______________________________________________
If yes, explain ______________________________________________________________________________
Does student have a juvenile or arrest record? ____________________________________________________
If yes, explain ______________________________________________________________________________
Please indicate academic level of students previous work ___________________________________________

Medical
Childs Physician ___________________________________________________ Phone (____) ____________
List any unusual home conditions that may have affected the child:(Family deaths, frequent moving, etc)______
__________________________________________________________________________________________
Student has difficulty in:

___ Speech

___ Vision

___ Hearing ___ ADD

___ ADHD

___ Other

Does student have any allergies?_______________________________________________________________

Does student have a current DH 3040 Student Health Examination? ___________________________________
Does student have a current DH 680 Florida Certificate of Immunization? ______________________________

Emergency Contact information (other than parents).

______________________________________ __________________ (____)___________ (____)__________
Name
Relationship
Home #
Work #
______________________________________ __________________ (____)___________ (____)__________
Name
Relationship
Home #
Work #
______________________________________ __________________ (____)___________ (____)__________
Name
Relationship
Home #
Work #
______________________________________ __________________ (____)___________ (____)__________
Name
Relationship
Home #
Work #
______________________________________ __________________ (____)___________ (____)__________
Name
Relationship
Home #
Work #

Spiritual
Do you attend church? ___ Yes ___ No Church Name___________________ Pastor Name_____________
Do you desire a biblical, Christ-centered education for your child? ____________________________________
Have you read our Educational Philosophy? ___ Yes

___ No

Do you desire your student to receive training according to the principles outlined in our Educational
Philosophy and do you support the school in its endeavors to encourage and to guide your student in applying
these to life? ___ Yes ___ No

Parent/Guardian Name

Date

Parent/Guardian Signature