Application for Admission – Cortez Adventist Christian School

Application for Admissions

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Date*

Student Information

Grade Entering*

Gender *

Male

Female

Student's Full Legal Name (First, Middle, Last)*

Birthdate*

Birthplace *

Age*

Student's Residence *

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Guardian Information

Father

Natural

Step

Foster

Full Name

First Last

Address (If different from Child's)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Cell Phone

Work Phone

Occupation

U.S. Citizen

Languages Used in Home

Church Affiliation

Mother

Natural

Step

Foster

Full Name

First Last

Address (If Different From Child's)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Cell Phone

Work Phone

Occupation

U.S. Citizen

Languages Used at Home

Church Affiliation

Guardian

Full Name

First Last

Address (If Different From Child's)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Cell Phone

Work Phone

Occupation

U.S. Citizen

Languages Used in Home

Church Affiliation

Emergency Information

Doctor

Doctor's Number

Emergency Contact 1

Number

Emergency Contact 2

Number