Salem Christian School

Student Enrollment Application Application Date: Student Information Full Name Address City Home Phone Age Sex Birth Date email Birth Place Zip

School Last Attended School Address

Last Grade Completed Family Information Fathers Name Marital Status: Married Employment Position Mothers Name Marital Status: Married Employment Position Fathers Cell Phone Children in family of school age if not applying: Name Age Work Phone Mothers Cell Phone Divorced Widow Separated Work Phone Divorced Widower Separated

Reason they are not applying:

Religious Information It is a requirement for admission to Salem Christian School that at least one parent of the student(s) be an active Christian attending a Bible believing church. Church Attending Address Pastor Name Medical Information Family Physician Phone Does the student have any physical impairments or allergies? Phone

Is the student immunization record up to date? Scholastic Information Has the student ever been expelled, dismissed, suspended or refused admission to another school? Why?

Has the student ever had disciplinary difficulty at school? Why? Does the student have a juvenile or arrest record? Explain Has the student ever used tobacco or non-prescription drugs of any kind? Explain Has the student ever failed an academic subject in school? Explain Please indicate the academic level of the students previous work: Excellent Good Average General Information How did you hear about this school? Poor

Reason for selecting this school

This enrollment application must be filled out completely before it can be processed. An Enrollment Application and Registration fee of $75.00 must accompany the application and is non-refundable. An interview with the parents and the student will be required before final acceptance. Salem Christian School has a racial nondiscriminatory policy and therefore, does not discriminate against members, applicants, students, and others on the basis of race, color or national or ethnic origin. I hereby pledge to pay my financial obligation to the school on the due date and understand that it may be necessary to withdraw my student if proper arrangements are not made on a past due account. I appreciate the standards of the school and do not tolerate profanity, obscenity in word or action, dishonor to God or the Word of God, or disrespect to the personnel of the school. I hereby agree to support all regulations of the school in the applicants behalf and authorize this school to employ discipline it deems wise and expedient for the training of my student. I understand that the school reserves the right to dismiss any student who fails to comply with the established regulations and discipline or whose financial obligations remain unpaid.

Fathers Signature

Mothers Signature

Date

Date