OFFICE USE ONLY:

PARK PLACE CHRISTIAN ACADEMY

201 Park Place Drive
Pearl, MS 39208
(601) 939-6229

___Birth Cert. ___DOB

___SS Card ___Ins Cd
___ Imm 121 ___HB
__________Check #
__________Cash
__________Date

APPLICATION FOR ADMISSION

Afterschool Care Needed:
Yes: ____ No: ____

TODAYS DATE: _____________________

STUDENT INFORMATION:

Applicant's Name ______________________________________________________________________________Grade Level _______

Last

Date of Birth __________

First

Middle

Male/Female

Preferred Name

Social Security #: __________________

Home Address _________________________________ City ___________ State ____ Zip _______

Number and Street

Home Phone_____________
Other Schools Applicant Has Attended:
Name of School

Location

Grade

Date

______________________________________________________________________________________
______________________________________________________________________________________
Present School ________________________________ Number of years attended ________
Complete address of present school
_____________________________________ City ___________________ State ______ Zip _______
Street Address

Principal/School Head ___________________________

Reason for Leaving____________________________________________________________________
Has your child ever been suspended from any school or asked to leave? Yes No (circle one)
If yes, please explain ______________________________________________________________
______________________________________________________________________________________
I/We hereby authorize Park Place Christian Academy to obtain all scholastic information and files from all
previous schools.
Has the applicant ever been recommended for special education classes or ever been diagnosed to have a
learning disability by a psychologist, psychiatrist or a specialist in learning disorders? Yes No
Has the applicant ever been retained? Yes No
Are you aware of any social adjustment or disciplinary problems outside the home?
Yes No If yes, please explain ____________________________________________________________
______________________________________________________________________________________
Is the applicant presently taking any medication? Yes No (circle one)If yes, what? __________________
______________________________________________________________________________________

Describe any allergy, illness, diseases or physical disabilities which either have affected or may affect your
child's general health, schoolwork, or participation in the school's athletic programs.
______________________________________________________________________________________
______________________________________________________________________________________
Has the applicant ever been recommended for alcohol/drug treatment or behavior/emotional treatment?
Yes No (circle one) If yes to any of the above, please explain:
______________________________________________________________________________________
______________________________________________________________________________________
PARENT INFORMATION
Parent

_____Father _____Mother _____Step-parent _____Guardian _____Other

Full Name __________________________________________

Home Address ______________________________________ Home Phone ________________
E-mail Address______________________________________
Occupation _____________ Name of Company _____________________________________________
Business Address ___________________________________Business Phone__________________
Cellular # _____________Pager # _____________Fax # ______________
Church Attending __________________________________ Member _____Yes ____No
Parent _____Father _____Mother _____Step-parent _____Guardian _____Other
Full Name __________________________________________
Home Address _________________________________________Home Phone____________________
E-mail Address______________________________________
Occupation ______________Name of Company_____________________________________________
Business Address ____________________________________Business Phone ____________________
Cellular # _____________Pager # _____________Fax # _______________
Church Attending __________________________________ Member _____Yes ____No
FAMILY INFORMATION
Parents Marital Status (check all that apply) ___Parents married ___Parents separated
___Parents divorced ___ Mother remarried ___ Father remarried ___Mother deceased __Father deceased
With whom does the student live? Name(s)
______________________________________________________
Relationship____________________________________________________________________________
____
If parents are separated, divorced or deceased, do you have ____legal custody or ____ power of attorney?
Who has legal custody?
______________________________________________________________________

List additional brothers and sisters:

Name/Age

____________________________
____________________________
____________________________

School (if applicable)

__________________________________
__________________________________
__________________________________

Grade

___________
___________
___________

Additional Information
Students Physician ______________________________________ Phone__________________________
Emergency Friend ______________________________________ Phone__________________________
Grandparent___________________________________________ Phone__________________________
Address _______________________________________________________________________________
Grandparent ___________________________________________ Phone__________________________
Address _______________________________________________________________________________
Names and phone numbers of person(s) to whom we may release your child:
Name________________________________________________Phone____________________________
Name________________________________________________Phone____________________________
Name________________________________________________Phone____________________________
Please include your parental perspective on your child. Include your childs strengths and abilities, special
areas of interest as well as areas of concern. We appreciate your assistance in helping us to know your child
better.
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Special Interests and Talents______________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

MISSION STATEMENT AND STATEMENT OF FAITH

MISSION STATEMENT:
Park Place Christian Academy partners with Christian parents to provide their children a Christ-centered
education founded on the Bible which fosters spiritual development and instills the vision and practice of
Christian excellence in academics, character, and service to others.
STATEMENT OF FAITH:
1. We believe in the absolute accuracy of the Word of God and that the Bible is verbally inspired and allsufficient as the Christians rule of life and practice (II Timothy 3:16, 17).
2. We believe in the total depravity of man through the fall of Adam (Genesis 3: Romans 5:12-17).
3. We believe that the one true God is manifested in three persons: Father, Son, and Holy Spirit, equal in
all things as eternity, omnipotence, omnipresence, and omniscience (Matthew 28:19; II Corinthians 13:14).
4. We believe in the virgin birth of Jesus Christ (Luke 1:26-35); His absolute sinlessness (II Corinthians
5:21); and in the complete justification of the believers in Christ (Acts 13:38, 39: Romans 5:1).
5. We believe in the present assurance of salvation (I John 5:11-13); the present possession of eternal life by
every true believer (John 5:24; 6:47); and the eternal security of the genuine believer (John 10: 28-30).
6. We believe that the ordinances of the Lords Supper and baptism by immersion are to be observed by the
church in the Lords absence. (Matthew 28:19; Acts 8:36-39; Romans 6:1-5; I Corinthians 11: 23-26; Acts
2:42)
7. We believe in the resurrection of all believers at the pre-millennial coming of Christ and in the review and
reward of believers according to their life and works. (Luke 14:14 John 5:28, 29: Romans 14: 10-12; II
Corinthians 5:10; I Corinthians 3: 11-15; I Corinthians 15: 22, 23)
8. We believe in the love of God for the entire world (John 3:16), the necessity for the new birth through the
Word of the Spirit of God (John 3:3-7; I Peter 1: 23-25), the indwelling of every true believer by the Holy
Spirit (I Corinthians 6:19, John 14:16, 17); the uselessness of human works and merit to obtain salvation.
(Romans 4:5; Ephesians 2:8, 9; Titus 3:5)
9. We believe in the finished work of Christ through which complete and eternal atonement for sins has
been effected. (John 19:30; Hebrews 9:26, 28; Titus 3:5)
10. We believe in salvation by grace alone through faith alone. (Ephesians 2:8, 9; Acts 15:30, 31)
11. We believe in the efficacy of the blood of Christ, apart from which there can be no salvation (Hebrews
9:22; Ephesians 1:7; Colossians 2:20; I John 1:7); His vicarious death (Romans 5:6-8; Luke 24:26-40); His
visible ascension (Luke 24:51, 51); His present enthronement (Hebrews 1:3); and His high priestly ministry
and advocacy. (Hebrews 7:25, 26; I John 2:1)
12. We believe that mankind is absolutely helpless and cannot please God in an unregenerate condition.
(Romans 3:9-19; 8:8)

13. We believe in the immediate entry into a literal hell by every person who dies without Christ (Luke
16:19-31); the resurrection of all such persons to stand before the Great White Throne of Judgment (John
5:28, 29; Revelation 20:11-13); and the consignment of all such persons into a lake of fire forever. (Matthew
25:46; Revelation 20:14, 15)
14. We believe in the separation from sin and the world by the Christian and a godly life to the glory of God.
(II Corinthians 6:14, 7:1; Titus 2:11-14)
15. We believe in the rapture of the church, at the coming of Christ, to meet Him in the air (I Corinthians
15:51-57; I Thessalonians 4:13-18); the revelation of Christ at His coming to the earth prior to the setting up
of His millennial kingdom (II Thessalonians 1:6-10); and the personal, literal reign of Christ over this earth of
one thousand years. (I Corinthians 15:24-28; Revelation 12:1-11; 20:6)
After acquainting yourself with Park Place Christian Academys Philosophy and Statement of Belief, describe
your expectations in regard to your childs education.
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Admission Procedure:
1. Submit completed application with a registration fee (non-refundable).
2. Submit copies of transcripts, immunization records, signed packet of authorization forms and
enrollment contracts.
3. Schedule an interview with the Lower Elementary Principal (for 1st - 3rd grades) or the Headmaster (for
4th - 12th grades).
As the Parent(s)/Guardian of the student applicant named hereinabove, I/we state that we are aware of the
Doctrinal Statement, Statement of Mission and Philosophy of Park Place Christian Academy and agree that
upon acceptance of the herein named student, I/we will pledge ourselves to work with Park Place Staff,
Administration and Faculty within these statements to the betterment of our student, and to assist and
cooperate with the school in the Christian education of my/our child. I understand that the enclosed
Application Fee is non-refundable. I further understand and acknowledge that continued enrollment of
my/our child, if admitted to Park Place, shall be subject to the payment of all fees and charges set forth on the
schedule of fees as periodically amended by Park Place and my/our childs compliance with Park Places
code of conduct and policies established by Park Place Christian Academy.
I understand that the school will not administer exams, issue report cards, or post grades to permanent
records until all charges are paid in full and all school property returned. I understand that Park Place
Christian Academy will not release records to anyone, including me, until the above terms have been
satisfied.
Your signature indicates that the information in the enrollment application is correct and that you have read
the Philosophy and Goals, that you are in agreement, and that you are under no financial obligation to any
former school in order that records may be released to Park Place Christian Academy. Final grade
placement is subject to Administrative approval, satisfactory completion of present grade, and verification of
records/credits from previous school(s).
____________________________________
Parent (Guardian)
Date

_______________________________________
Guardian
Date

NON-DISCRIMINATORY POLICY
Park Place Christian Academy admits students of any race, color, national and ethnic origin to all
the rights, privileges, programs and activities generally accorded or make available to students at the
school. Park Place Christian Academy does not discriminate on the basis of race, color, national and ethnic
origin in administration of its educational policies, admissions, policies, scholarship and loan programs,
athletic and other school-administered programs.

THE FOLLOWING MUST BE TURNED IN

WITH THE COMPLETED APPLICATION:
1. Copy of Birth Certificate
2. Copy of Social Security Card
3. Copy of Current Immunization Record
4. Copy of grades and test scores from school last
attended
5. Copy of insurance card (requested but not
required)