Adelfiha Christian Academy Registration Form

Step 1 - Student Information

Student's First Name

Student's Middle Name

Student's Last Name

Nick Name

Select Grade Select GradeKindergartenGrade 1Grade 2Grade 3Grade 4Grade 5Grade 6

Sex: Sex: Male Female

Does the student have any special custody? Does the student have any special custody? Yes No

Please specify (e.g. mother only, father only)

Date of birth (Month/Day/ Year)

Place of Birth

Citizenship

Does the child have a Legal Guardian? (e.g. Relative or friend) Does the child have a Legal Guardian? (e.g. Relative or friend) Yes No

Legal Guardians Name

Legal Guardians Phone Number

Street Address

City

Province

Postal Code

Phone Number

Step 2 - Parent Information

Mother/Guardian Name

Address

Occupation

Employer/School

Employer/School Address

Marital Status

Home Phone

Work/School Phone

Cell Phone

Email Address

Step 3 - Parent Information

Father/Guardian

Address

Occupation

Employer/School

Employer/School Address

Marital Status

Home Phone

Work/School Phone

Cell Phone

Email Address

Step 4 - Personal Information

Special diet:

Special health conditions or allergies:

Step 5 - Billing Information

Bill Payer's Full Name (Mr./Ms./Mrs./)

Street Address

Apt.#

City

Province

Postal Code

Day Telephone #

Evening Telephone #

Email Address

Please type name here for signature

Date

Step 6 - Submit Your Application Privacy Policy |Terms of Use

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